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Based on record review and interview the facility failed to ensure the initial in-service training for emergency preparedness contained the facility emergency preparedness plan as required.

Findings:

Record review of the facility emergency preparedness training documentation did not show the in-service training included the facility emergency preparedness plan as required.

On 07/28/21 at 12:11 pm the surveyor asked staff B why the facility emergency preparedness plan was not included in the emergency preparedness initial employee training. Staff B stated that several portions of the plan are included with their online training but will amend the initial training to included the facility emergency preparedness plan.

Based on observation and interview the facility failed to ensure all corridor doors could be opened with one action as required.

Findings:

On 07/28/21 at 10:05am the surveyor observed a deadbolt with a turn knob on several corridor doors within the facility.

On 07/28/21 at 10:05am the surveyor asked Staff D why there were deadbolts on the emergency egress access corridor doors. Staff D stated they did not know other than for security but will remove them off to be in compliance. The surveyor explained it would take more than one action for a person to gain access to the emergency exit egress corridor pathway which is not complaint to code.

The facility failed to ensure hazardous areas were protected as required.

Findings:

On 07/28/21 at 01:38pm the surveyor observed penetrations in a hazardous area electrical closet which would allow smoke and fire to spread to other areas of the facility.

On 07/28/21 at 01:38pm the surveyor asked staff D why there were penetrations around the electrical conduit going through the ceiling tiles. Staff D stated he did not know why but will get the areas filled to be compliant.

Based on record review and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were maintained as required.

Findings:

Record review showed the facility did not have test and balance inspections for 2020, 2019, and 2018. The facility had one annual test and balance inspection from ASI dated 06/15/21 which only had OR 1 and OR 2 tested for compliance but the facility test and balance failed to include the following areas to ensure they met ventilatory requirements as required: sterile processing, decontamination, substerile area, and surgical area house keeping closet.

Record review showed the facility's relative humidity (RH) policy indicated the RH range was 20-60%RH where ASHRAE 170-2008 table 7.1 indicates the range should be 30-60%.

On 07/28/21 at 10:27am the surveyor asked staff D why they only have the one test and balance inspection from ASI dated 06/15/21. Staff D stated they he only recently started and he doesn't know why the people did not do it before him. Staff D stated the facility was going through bankruptcy with a different management group before their management group took over. Staff D stated they will ensure all the proper areas will be tested to ensure ventilatory requirements are met to be in compliance.

On 07/28/21 at 1:53pm the surveyor asked staff B why their RH policy indicated 20-60%. Staff B stated they are in transition and the surgical manager is new and will be making the proper changes from the old managements policies in order to be in compliance.

Based on observation and interview the facility failed to ensure fire extinguisher(s) located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 07/28/21 at 11:22am the surveyor observed a ABC class fire extinguisher and one K class fire extinguisher in the kitchen with no placard posted next to it as required.

On 07/28/21 at 11:22am the surveyor asked asked staff D why there was no placard on the ABC fire extinguisher when it was installed. Staff D stated they had inhouse staff install it and they probably were not aware of the requirement. Staff D stated they would get the appropriate placard installed for the fire extinguisher.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the fire drills for 2020 and 2019 did not document transmission of a fire alarm signal.

On 07/28/21 at 11:17am the surveyor asked staff D why the fire drills did not contain documentation of the transmission of a fire alarm signal as required. Staff D stated that he was not familiar with that requirement but will ensure it is documented from this point forward.

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2020, 2019, and 2018 were not completed.

On 07/28/21 at 2:33pm the surveyor asked staff D for the annual fire rated door assembly inspections and why they were not completed. Staff D stated he is newly hired and did not know why the previous staff did not complete the annual fire rated door assembly inspections but he will make sure they are completed as required.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed.

On 07/28/21 at 11:23am during record review the surveyor asked Staff D for the EES and Medical Gas building system risk assessments. Staff D stated he is new to healthcare life safety but will get the building system risk assessment completed.

Based on record review and interview the facility failed to ensure annual inspection of the medical gas system and maintain the documentation of the inspection(s) as required.

Findings:

Record review showed the facility failed to have the medical gas system inspected for 2020, 2019, and 2018.

On 07/28/21 at 2:17pm the surveyor asked staff D why the facility did not have the 2020, 2019, and 2018 annual medical gas inspections. Staff D stated they did not know as they just started but they have do not know. Staff D stated they would schedule their vendor to get an annual medical gas inspection to be in compliance.

Based on record review and interview the facility failed to ensure line isolation monitor (LIM) inspection and testing was completed for the surgical suite.

Finding:

Record review showed the facility did not complete LIM inspection and testing for 2020, 2019 and 2018.

Record review showed the facility did not complete annual impedance testing of patient care related electrical receptacles.

On 07/28/21 at 1:12pm the surveyor asked staff D for documentation for the inspection and testing for the surgical area LIM system. Staff D stated the LIM annual inspections were not completed for 2020, 2019 and 2018.

On 07/28/21 at 1:26pm the surveyor asked staff D why the annual impedance testing of patient care related electrical receptacles was not completed for 2020, 2019, and 2018. Staff D stated he is new to the position, and it will get scheduled to be complete annually. Staff D stated he does not know why it was not done by the person before him.

Based on record review and interview the facility failed to ensure operating room staff completed specific training on features of fire protection and fire loss prevention in operating rooms as required.

Findings:

Record review showed no fire drills for operating room staff for emergency procedures which included each of the the following required elements: equipment fires, alarm activation, evacuation, equipment shutdown, and control operations in addition to continuing education specific to operating room fire prevention. The operating room fire drills and emergency procedures training did not include surgeons/doctors as required in NFPA 99, 15.13.

On 07/28/21 at 10:04am the surveyor asked staff D if the operating room staff performed practical fire drills in the operating room which included each of the items as outlined in the CMS 2786R document at K933. Staff D stated they do regular fire drills but will document each of the elements of K933 in the future. The surveyor stated they will have to include each of the outlined items in K933 to also include doctors in the operating room fire drills as required.