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UNITY PSYCHIATRIC CARE-CLARKSVILLE
Local, State, Tribal Collaboration Process
Tag No.: E0009
Based on record review, the facility failed to include a process for cooperation and collaboration with local, tribal, regional, state, and federal Emergency Preparedness (EP) officials in efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.
The finding included:
Record review of the facility's Emergency Preparedness plan on 11/17/25 at 11:00 AM, revealed the facility failed to document it's efforts to contact emergency preparedness officials and, when applicable, participate in collaborative and cooperative emergency planning efforts.
This finding was verified by the maintenance director during the survey and was acknowledged by the administrator during the exit conference on 11/17/25.
EP Testing Requirements
Tag No.: E0039
Based on record review, the facility failed to conduct and document exercises to test the emergency plan.
The finding included:
Record review of the facility's Emergency Preparedness plan on 11/17/25 at 11:00 AM, revealed the facility had not conducted two (2) full-scale drills or (1) full-scale drill and (1) table-top exercises involving local, state, or federal officials that tested elements of the facility's EP Plan.
This finding was verified by the maintenance director during the survey and was acknowledged by the administrator during the exit conference on 11/17/25.
Exit Signage
Tag No.: K0293
Based on record review, the facility failed to maintain the exit signs.
The finding included:
Record review on 11/17/2025 at 10:30 AM, revealed the facility failed to provide documentation for the annual 90 min testing on the exit signs.
National Fire Protection Association NFPA 101, 19.2.10.1 (2012 Ed), NFPA 101, 7.10.9.2 (2012 Ed), NFPA 101, 7.9.3.1.1 (3) (2012 Ed)
This finding was verified by the maintenance director during the survey and was acknowledged by administrator during the exit conference on 11/17/2025.
Maintenance, Inspection and Testing - Doors
Tag No.: K0761
Based on record review, the facility failed to maintain the fire doors.
The finding included:
Record review on 11/17/2025 at 10:35 AM, revealed the facility failed to provide documentation for the annual fire door inspection.
National Fire Protection Association NFPA 101, 19.7.6 (2012 Ed), NFPA 101, 4.6.12.1 (2012 Ed), NFPA 101, 8.3.3.1 (2012 Ed), NFPA 80, 5.2.1 (2010 Ed)
This finding was verified by the maintenance director during the survey and was acknowledged by administrator during the exit conference on 11/17/2025.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on record review, the facility failed to maintain the emergency generator.
The finding included:
Record review on 11/17/2025 at 10:40 AM, revealed the facility failed to provide documentation for the annual load bank testing of the emergency generator.
National Fire Protection Association NFPA 101, 19.5.1.1 (2012 Ed), NFPA 101, 9.1.3.1 (2012 Ed), NFPA 110, 8.4.2.3 (2010 Ed)
This finding was verified by the maintenance director during the survey and was acknowledged by administrator during the exit conference on 11/17/2025.