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Based on record review and interview, the hospital failed to ensure the emergency preparedness policies and procedures addressed the facility's role in emergencies where the President declares a major disaster.

Findings:

Record review of the emergency preparedness policies and procedures showed the facility did not establish and maintain a policy and procedure in the emergency plan describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver. The policy did not exist.

On 07/18/18 at 10:00 am the surveyor asked Staff B, for the facility policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff B stated the facility was unaware of the policy.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that addressed the means in the event of an evacuation, to release patient information to include the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).

Findings:

Record review of the facility emergency preparedness communication plan did not contain methods for sharing information and medical documentation for patients under the facility's care with other health care providers to maintain continuity of care in the event of an evacuation as required.

On 07/18/18 at 1:33 pm the surveyor asked Staff B for documentation to verify the facility had developed an emergency preparedness communication plan which included how the facility would share information for patients under the facility's care as necessary with other health care providers in the event of an emergency. Staff B stated the facility was unaware of this requirement and had not developed an emergency preparedness communication plan that included sharing information. Staff B stated the facility would develop a plan to address sharing information in the event of an evacuation as permitted under 45 CFR 164.510(b)(4).

Based on record review and interview the facility failed to ensure annual and initial in-service training for staff, and individuals providing services under arrangement, on the emergency preparedness plan for 15 (staff A , staff C, staff D, staff E, staff F, staff G, staff H, staff I, staff J, staff K, staff L, staff M, staff N, staff O, and staff P) of 22 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for existing staff, and individuals providing services under arrangement for the following staff:

Staff A with the date of hire 10/23/12 had not received initial or annual in-service training for emergency preparedness plan.

Staff C with the date of hire 03/13/14 had not received initial or annual in-service training for emergency preparedness plan.

Staff D with the date of hire 05/21/18 had not received initial in-service training for emergency preparedness plan.

Staff E with the date of hire 02/13/17 had not received annual in-service training for emergency preparedness plan.

Staff F with the date of hire 07/2/01 had not received initial or annual in-service training for emergency preparedness plan.

Staff G with the date of hire 11/4/13 had not received initial in-service training for emergency preparedness plan.

Staff H with the date of hire 10/2/15 had not received initial or annual in-service training for emergency preparedness emergency plan.

Staff I with the date of hire 11/25/09 had not received initial or annual in-service training for emergency preparedness plan.

Staff J with the date of hire 07/30/99 had not received initial or annual in-service training for emergency preparedness plan.

Staff K with the date of hire 09/24/10 had not received initial or annual in-service training for emergency preparedness plan.

Staff L with the date of hire 06/25/18 had not received initial in-service training for emergency preparedness plan.

Staff M with the date of hire 01/22/18 had not received initial in-service training for emergency preparedness plan.

Staff N with the date of hire 02/23/15 had not received initial or annual in-service training for emergency preparedness plan.

Staff O with the date of hire 05/01/18 had not received initial in-service training for emergency preparedness plan.

Staff P with the date of hire 11/16/15 had not received initial or annual in-service training for emergency preparedness plan.

The emergency preparedness training records for initial and or annual in-service do not exist for Staff A, Staff C, Staff D, Staff E, Staff F, Staff G, Staff H, Staff I, Staff J, Staff K, Staff L, Staff M, Staff O, and Staff P.

On 07/18/18 at 11:15 am the surveyor asked Staff B, and Staff A for documentation of training in-service for new, existing staff members, and individuals providing services under arrangement/contract. Staff B stated the facility did do some of the emergency preparedness training, but not all staff have taken the training. Staff B stated the facility would continue to work on the staff training for emergency preparedness.

Based on observation and interview the facility failed to ensure each egress access door could be opened with only one action.

Findings:

On 01/18/18 at 10:05 am a keyed lock and a lock with a turn knob was observed to be installed on two horizontal sliding wood exit access corridor doors.

On 01/18/18 at 10:05 am Staff A was asked why there were two sliding doors with locks which requires two actions to open. Staff A stated he did not know but can take the lock off of each door. The surveyor explained it would take more than one action for a person to gain access to the exit corridor from inside each of the two offices where the wooden sliding doors are located.

Based on observation and interview the facility failed to ensure hazardous areas were equipped with self-closing hardware as required.

Findings:

On 07/18/18 at 10:57 am the Acute Care Unit (ACU) janitor closet was observed to not have self-closing hardware.

On 07/18/18 at 10:57 am the surveyor asked Staff A why self-closing hardware was not installed onto the hazardous area janitors closet. He stated he did not know why but will have the self-closing hardware installed.

Based on record review and interview the facility failed to ensure monthly emergency powered battery backed up lighting testing was completed.

Findings:

Record review of the monthly emergency powered battery backed up lighting testing showed the length of testing was not documented as required. Monthly testing should be for 30 seconds for each battery backed up emergency light fixture.

On 07/16/18 at 11:30 am the surveyor asked Staff A how long the staff checked the battery powered emergency lighting monthly. Staff A stated the lights should be checked monthly for 30 seconds and each year for 90 minutes. The surveyor stated that is correct but the facility documentation for monthly testing does not indicate the length of time the staff tested the lights. Staff A stated they would make sure to include the length of time on their monthly logs.

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

Findings:

On 07/18/18 at 9:40 am a K class fire extinguisher was observed in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher.

On 07/18/18 at 9:40 am Staff A stated he would get with their fire service vendor to get the appropriate placard(s) for each of the fire extinguishers that are installed within the kitchen.


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 observation and interview the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over ignition sources.

Findings:

On 07/18/18 at 2:59 pm the surveyor observed one ABHR dispenser installed over a light switch in the exam room.

On 07/18/18 at 2:59 pm the surveyor asked Staff A why the ABHR was installed over the lights switch. Staff A stated he did not know why and will have it installed correctly.

On 07/18/18 at 3:02 pm the surveyor observed one ABHR dispenser installed over a light switch located in the unit exam room.

On 07/18/18 at 3:02 pm the surveyor asked Staff A why the ABHR was installed over the light switch. Staff A stated the Purell label indicates it is alcohol free. The surveyor read the list of ingredients and it indicated as an inactive ingredient phenoethanol.

Based on record review and interview the facility failed to ensure the fire alarm systems were tested and maintained as required.

Findings:

Record review of fire alarm system testing and maintanance did not include documentation of the smoke detectors having sensitivity testing on installation and every other year thereafter.

On 07/17/18 at 9:45 am the surveyor asked Staff A when the building was built. Staff A stated 1997. The surveyor asked if that was the year the smoke detectors were first installed and Staff A stated yes. Staff A went on to say the smoke detectors had been recently replaced. The surveyor explained there should be testing records of the original smoke detectors in addition to the acceptance testing of the recently installed new smoke detectors. Staff A did not provide the surveyor with any smoke sensitivity testing documentation from the time they were first reqeusted till the last day of the survey at the exit with the facility.



Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Based on observation and interview the facility failed to ensure sprinkler heads were installed where the spray pattern would not be hindered by surrounding objects.

Findings:

On 07/18/18 at 10:57 am a sprinkler head was observed to be obstructed by a florescent light which was installed with in several inches of the sprinkler head, and the spray pattern of the sprinkler head would hit the light hindering the spray pattern of the water throughout the room.

On 07/18/18 at 10:57 am the suryveor asked Staff A why the light was installed so close to the pendant sprinkler head. Staff A stated he did not know why but he will move the light so it will not affect the sprinkler head.

Based on observation and interview the facility failed to ensure smoke barriers were smoke resistant.

Findings:

On 07/19/18 at 10:01 am penetrations were observed in the ceiling tiles located throughout the facility which would allow fire and smoke to spread into the plenum space then throughout the facility.

On 07/19/18 at 10:34 am seven holes were observed in the fire barrier separating the ACU unit and the office spaces.

On 07/19/18 at 10:37 am the surveyor asked Staff A why the penetrations are not filled throughout the facility. Staff A stated they were just recently advised by the state mental health department they needed to have a preventative maintenance program for penetrations.

Based on observation and interview the facility failed to ensure electrical wiring was protected.

On 07/18/18 at 11:42 am the surveyor observed the cover for the bottom of a suspended heater in the mechanical room was off and had the wires exposed.

On 07/18/18 at 11:42 am the surveyor asked Staff A why the cover was left off the bottom of the suspended heater. Staff A stated they had been repairing it but he thought it was completed. Staff A stated he would get the bottom replaced.

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 2016 and 2017 did not document transmission of a fire alarm signal. The documentation of verification of a fire alarm signal for each fire drill did not exist.

On 07/18/18 at approximately 11:17 am the surveyor stated to Staff A the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff A stated they would add that to the fire drill documentation.

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 2017 were not completed and the documentation did not exist.

On 07/16/18 at 12:35 pm the surveyor asked Staff A for the annual fire rated door assembly inspections. Staff A stated the inspection was not completed for 2017 and the documentation did not exist.

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 07/18/18 at 11:23 am during record review the surveyor asked Staff A for the EES and Medical Gas building system risk assessments, and Staff A stated he had not completed the medical gas or EES building system risk assessments.

Based on record review and interview the facility failed to ensure electrical receptacles in patient care areas were tested annually as required.

Findings:

Record review showed the facility did not test patient care electrical receptacles for 2015, 2016 and 2017.

On 07/16/18 at 3:33 pm Staff A was asked for the patient care area electrical receptacle testing for 2015, 2016 and 2017. Staff A failed to provide the impedance testing documentation for the facility. The electrical receptacle testing documentation does not exist for 2015, 2016 and 2017.

Based on observation and interview the facility failed to ensure emergency electrical receptacles have a distinctive color or marking.

Findings:

On 07/18/18 at 11:40 am each of the emergency electrical outlets throughout the facility were observed to not be marked nor have a distinctive color indicating they were emergency powered electrical receptacles.

On 07/18/18 at 11:40 am the surveyor asked Staff A why the emergency powered electrical receptacles were not marked or did not have a distinctive color. Staff A stated they were what was installed when the building was built but they will get them marked correctly.



Electrical Systems - Essential Electric System Receptacles
Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2015, 2016 and 2017, as the documents do not exist.

On 07/18/18 at 1:52 pm Staff A was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016 and 2017. Staff A stated the annual emergency generator fuel quality tests have never been done and the documents do not exist.