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Based on record review and interview, the facility failed to have a complete emergency preparedness plan in accordance with the newly mandated emergency preparedness proram. This was evidenced by the emergency plan that failed to address their patient population at risk and how to meet their needs in the event of a disaster and failed to address a process for cooperation and collaboration with external emergency officials during a disaster. This affected patients, staff and visitors and could result in increased confusion and a delay in adequate response, in the event of an emergency.

Findings:

During record review with the DPO from 8/7/18 to 8/9/18, the emergency preparedness plan was reviewed.

8/8/18
1. At 2:45 p.m., the facility emergency plan failed to identify the patient population that would be at risk during an emergency and the facility's plan to address their needs.

2. At 2:47 p.m., the facility emergency plan failed to address collaboration and cooperation with local, regional, State and Federal emergency officials during a disaster. The DOP stated he was not familiar with the Requirements of the New Emergency Preparedness program.

Based on record review and interview, the facility failed to develop a complete emergency preparedness policies and procedures. This was evidenced by not having a written procedures for tracking their patients and staff during and after a disaster, by not having a policy on the protection of the confidentiality of their patients medical records during an evacuation and by not having a complete process for safe evacuation from the facility or for sheltering in place. This affected all clients and staff and could result in a delay in ensuring all patients and staff health and safety in the event of an emergency.

Findings:


During record review with the DPO from 8/7/18 to 8/9/18, the emergency preparedness plan was reviewed.

8/8/18
1. At 3:05 p.m., the facility's emergency preparedness policies and procedures failed to address procedures for tracking their patients and staff during a disaster. The DPO said he was not familiar with the requirements of the new emergency preparedness program.

2. At 3:15 p.m., the facility emergency preparedness policies and procedures failed to address the preservation and confidentiality of their patients' medical records in the event of a disaster.

3. At 3:20 p.m., the facility emergency preparedness policies and procedures failed to address safe evacuation from the facility including transportation and primary and alternate means of communication with staff and external emergency preparedness officials.
4. At 3:25 p.m., the facility emergency preparedness policies and procedures failed to address a means of sheltering in place.

8/9/18
5. At 9:15 a.m., during interview with nursing staff on their process for tracking of patients during a disaster, they stated there was a Cardex at the nursing station with the census of the patients and they would utilize the Cardex.
Staff verbalized their procedures that would be done during a disaster but was unable to verify their procedures in the written emergency preparedness plan.

Based on record review and interview, the facility failed to develop a complete emergency preparedness communication plan. This was evidenced by failure to address procedures for providing information to authority having jurisdiction/designee, by no method for sharing information and medical documentation with other healthcare providers and by no method for sharing their emergency plan with their patients and their family members or representatives. This could result in facility not prepared for a disaster and possible harm to patients, staffs and visitors, in the event of an emergency disaster.

Findings.
During record review with the DPO form 8/7/18 to 8/9/18, the emergency preparedness plan was reviewed.

8/8/18
1. At 3:32 p.m., the facility's emergency plan failed to address method for sharing information and medical documentation for patients under their care with other healthcare providers.

2. At 3:35 p.m., the facility's emergency plan failed to provide documents to show procedures for providing information about the facility occupancy, needs and ability to provide assistance to the authority having jurisdiction/designee.

3. At 3:36 p.m., the facility's emergency preparedness communication plan failed to indicate methods of sharing their emergency plan with their patients and their representative or family members. The DPO said he was not familiar with the requirements of the new Emergency Preparedness Program.

Based on record review and interview, the facility failed to conduct drills to test their new emergency preparedness plan and failed to train their staff on their new emergency preparedness plan. This was evidenced by failure to provide documents to show two of two disaster drills based on their new emergency preparedness plan were conducted and no staff training on their new emergency preparedness plan was done. This could result in facility not prepared for a disaster and possible harm to patients, staffs and visitors, in the event of an emergency disaster.


Findings.
During record review with the DPO from 8/7/18 to 8/9/18, the emergency preparedness plan was reviewed.

8/8/18

1. At 10:43 a.m., the Pharmacy staff stated they were not familiar with their role in the event of a disaster according to their new emergency preparedness plan.

2. At 3:40 p.m., during interview with facility staff, they stated they were not familiar with the facility's new emergency preparedness plan. The Staff stated they were not trained on the emergency preparedness plan.

3. At 3:50 p.m., the facility records failed to indicate two disaster drills were done based on their new emergency preparedness plan. The Facility disaster drill records failed to indicate one full scale community based drill and another full-scale community based or a table-top meeting using relevant discussion relating to their new emergency disaster plan.

8/9/18

4. At 9:35 a.m., the Director of Nursing stated that new staff were trained on the emergency preparedness plan during orientation. There was no document to show staff were trained on their new emergency preparedness plan.

5. At 4:55 p.m., the facility's new emergency preparedness plan failed to indicate a policy and procedures for initial and annual training of staff on their new emergency preparedness program.

Based on observation and record review, the facility failed to maintain their cooking equipment. This was evidenced by failure to provide documents to show inspection and servicing of the cooking equipment in the Kitchen. This affected one of nine smoke compartments. This could cause cooking equipment to malfunction and could possible harm patients and staff in the event of a disaster.


NFPA 96, Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Editions

11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

11.7.2 Cooking equipment that collects grease below the surface, behind the equipment, or in cooking equipment flue gas exhaust, such as griddles or char-broilers, shall be inspected and, if found with grease accumulation, cleaned by a properly trained, qualified, and certified person acceptable to the authority having jurisdiction.


Findings:

During a tour of facility with the Director of Plant Operations from 8/7/18 to 8/9/18, the Kitchen was observed and maintenance record reviewed.

On 8/7/18 at 2:50 p.m., the Kitchen was equipped with 8 burner gas stove, griddle, ovens and a deep fryer. The Facility failed to provide documents to show annual inspection and servicing of the cooking equipment. During interview with the Director of Plant Operations, he stated the kitchen staff was responsible for the maintenance of the kitchen equipment. On 8/8/18 at 8:28 a.m., during interview with the Kitchen Staff, he stated the maintenance staff had the responsibility of maintaining the kitchen equipment.

Based on observation, record review and interview, the facility failed to maintain their fire alarm system in a reliable operating condition. This was evidenced by no documentation of fire alarm panel batteries testing. This affected the main hospital and the outpatient clinic. This could result in a delay in notification of a fire to residents and staff and potential harm to patients and staff in the event of a fire emergency.

NFPA 101, Life Safety Code 2012 Edition

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72 ire Alarm Code 2010 Edition,

14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system.

14.2.1.2.2 System defects and malfunctions shall be corrected.

14.2.5.5 Testing shall include verification that the releasing circuits and components energized or actuated by the fire alarm system are electrically monitored for integrity and operate as intended on alarm.

14.2.5.6 Suppression systems and releasing components shall be returned to their functional operating condition upon completion of system testing.


Table 14.4.5 Testing Frequencies

6. (d) Sealed lead-acid type

(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed.)
initial/reacceptance annual
(2) Discharge test (30 minutes) initial/reacceptance annual
(3) Load voltage test initial/reacceptance semi-annual

FIndings:

During a tour of facility with the Director of Plant Operation from 8/7/18 to 8/9/18, the fire alarm system maintenance record was reviewed.

Main Hospital and Outpatient Building
On 8/8/18 at 9:18 a.m., the facility failed to provide documents to show complete testing of facility fire alarm panel components. The Facility failed to provide documents to show charger test, discharge test and load voltage test of their fire alarm panel batteries. The Director of Plant Operations stated the vendor used a tool to test the fire alarm panel batteries. There was no document to show the fire alarm batteries testing methods meets the Code requirement. The Director of Plant Operations was given until 8/10/18 at 10 a.m., to produce the documents but none was received.

Based on document review and interview, the facility failed to provide complete documentation of smoke detectors sensitivity testing. This was evidenced by failure to provide documents of sensitivity test of their system based smoke detectors. This affected main hospital and outpatient clinic building. This could result in the delay in notification of fire and the potential of harm to staff and patients.

NFPA 101, Life Safety Code, 2012 Edition

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.2.10.1.1 Where required by another section of this Code, single-station and multiple-station smoke alarms shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code, unless otherwise provided in 9.6.2.10.1.2, 9.6.2.10.1.3, or 9.6.2.10.1.4.
9.6.2.10.1.2

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.


14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency (ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturers published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)



Findings

During tour of the facility with the Director of Plant Operations from 8/7/18 to 8/9/18, the fire alarm system records were reviewed.


Main Hospital and Outpatient Building
On 8/8/18 at 8:40 a.m., the Director of Plant Operations said the facility was equipped with an addressable fire alarm panel. The Facility failed to provide documents to show completed sensitivity test report was conducted within the last 2 years. The Director of Plant Operations stated he has scheduled his vendor to conduct a sensitivity testing.

Based on observation, the facility failed to maintain their automatic sprinkler system in reliable operating condition. This was evidenced by incomplete documentation of maintenance, inspection and testing of the automatic fire sprinkler system. This affected main hospital and outpatient building. This could result in reduced effectiveness of the sprinkler system and cause injury to patients from fire.

National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 Edition

19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection System 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer


5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.


13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification


13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

Findings:

During a tour of the facility with the Director of Plant Operations from 8/7/18 to 8/9/18, the sprinkler system was observed and maintenance record reviewed.


Main Hospital and Outpatient Building
1. On 8/7/18 at 2:47 p.m., the Facility maintenance records failed to indicate the sprinkler system's components were inspected monthly. During interview with the Director of Plant Operation, he stated he was unaware of the new code requirements for the sprinkler system.

Main Hospital
2. On 8/7/18 at 2:55 p.m., there were built-up of debris observed on sprinkler heads in the Kitchen by the ventilation vents

Based on observation and interview, the facility failed to maintain equipment fire safety to prevent fire. This was evidenced by a swimming pool electrical pump installed by facility staff that caught on fire and malfunctioned. This affected the main hospital. This could cause harm to patients in the event of a widespread fire.

NFPA 101, Life Safety Code, 2012 Edition
19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having juris-
diction.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable
NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or opera- tion to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

NFP 70, National Electrical Code, 2011 Edition
680.21
(A) Wiring Methods. The wiring to a pool motor shall comply with (A)(1) unless modified for specific circumstances by (A)(2), (A)(3), (A)(4), or (A)(5).
(1) General. The branch circuits for pool-associated motors shall be installed in rigid metal conduit, intermediate metal conduit, rigid polyvinyl chloride conduit, reinforced thermosetting resin conduit, or Type MC cable listed for the location. Other wiring methods and materials shall be permitted in specific locations or applications as covered in this section. Any wiring method employed shall contain an insulated copper equipment grounding conductor sized in accordance with 250.122 but not smaller than 12 AWG.

Findings:

During a tour of the facility with the Director of Plan Operations from 8/7/18 to 8/9/18, the pool area was observed. The patients have used the swimming pool according to staff.

Main Hospital
On 8/7/18 at 12:05 p.m., there were scorched pine needles and scones on top of the fence, smoked damaged fence, burn marks on the concrete bottom, and burnt and warped piping tube in the swimming pool pump enclosure indicating that there was a fire in the area. During interview with the Director of Plant Operations, he stated on 7/29/18 the swimming pool pump was seen on fire and staff used the fire extinguisher to put the fire out. The Nursing Supervisor called 911 and the Duty Engineer met with the fire department to assess and ensure that the fire was out. At 12:30 p.m., the maintenance record indicated on 12/24/17, the swimming pool pump broke and staff replaced the pool pump. At 2:45 p.m., during interview with the Director of Plant Operations, he stated he replaced the swimming pool pump. He stated he could not provide manufacturer specification for installation and maintenance of the swimming pool pump he replaced on 12/24/17. He could not provide documentation of his qualifications for the installation of the pool pump. He stated it was a simple installation and no electrical installation was needed, and he confirmed he was not a certified electrician. There was no evidence that the swimming pool pump was installed according to all applicable codes. The swimming pool pump replaced by the facility staff on 12/24/17 caught on fire on
7/29/18.

Based on observation, interview and document review, the facility failed to maintain the elevators fire-fighter services. This was evidenced by incomplete documentation of testing and servicing the elevator fire-fighter emergency services. This could result in mal-function of the elevators and possible harm to patients and staff. This affected nine of nine smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition

19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.

9.4.6.2 All elevators equipped with fire fighters ' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASMEA17.1/CSA B44, Safety Code for Elevators and Escalators.

Findings:

The elevator inspection documents were reviewed with the Director of Plant Operations from 8/7/18 to 8/9/18. Elevator 1 and 2 records were reviewed. Elevator 1 and 2 were equipped with fire-fighter service button.

On 8/8/18 at 10:40 a.m., the Facility failed to provide complete documents to show monthly maintenance and services of the elevators fire fighter emergency operations since January 2018. The Director of Plant Operations stated the fire fighters emergency services were operated every two months.

Based on interview and record review, the facility failed to train their staff on their emergency procedures as evidenced by staff unfamiliar with facility's fire procedures. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in harm to patients and staff. This affected nine of nine smoke compartments.

NFPA 101 Life Safety Code 2012 Editions

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon
staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy' s fire safety plan

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all
of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation



Findings:


During tour of the facility with the Director of Plant Operation from 8/7/18 to 8/9/18, staff were interviewed on their facility fire safety procedures.

Main Hospital
1. On 8/7/18 at 3:15 p.m., during interview with the facility's operator, she failed to indicate she will notify the fire department in the event of a fire.

2. On 8/7/18 at 3:30 p.m., staff were interviewed on the procedures they followed during the fire at the swimming pool on 12/24/17. The Staff indicated the fire department was late to the facility because they were unable to locate the facility address. The Staff stated they did not activate the manual pull station but did call 911. The Staff did not ensure the fire department had the correct address, which caused the delay in responding. The Facility's fire safety plan indicated, the manual pull stations will be activated, to notify the operator and the operator will call the fire department to make sure they respond immediately.

3. On 8/8/18 at 9:41 a.m., a staff was asked which keys operated the manual pull box but was unfamiliar with which key operated the manual pull box.

4. On 8//8/18 at 10:43 during interview with facility staff 1, he failed to indicate he would call 911 during fire.
5. On 8/9/18 at 9:15 a.m., staff were interviewed to determine their knowledge of their fire procedures. Two of two staffs failed to state their procedure of notifying the fire department during fire.

6. On 8/9/18 9:55 a.m., during interview, RN3 stated he has not participated in a fire drill since he started 8 months ago, and he was unfamiliar with the facility's evacuation procedures.

Based on observation, the facility failed to maintain their designated and non-designated smoking area from accidental fire by the careless disposal of cigarette butts. This was evidenced by cigarette butts disposed on facility grounds in non-designated and designated smoking area. This affected the main hospital and could result in a fire and possible harm to patients and staff.

Findings:

During the tour of the facility with the Director of Plant Operations from 8/7/18 to 8/18/18, the facility exterior egress path was observed.

Main Hospital
1. On 8/7/18 at 11:55 a.m., there was an accumulation of cigarettes butts on the ground of the non-smoking area, behind the generator, including a cigarette butt with ashes on the tip. There were signs on the picnic benches and over the tent indicating "no smoking". The non-smoking area was equipped with a safety ash tray. Director of Plan Operation confirmed this was not the designated smoking area.

2. At 12 p.m., there was an accumulation of cigarettes butts on the grounds of the smoking area west of the building. There were vegetation by the smoking area. The smoking area was equipped with safety ash trays.