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The facility failed to ensure that an emergency preparedness program was developed and maintained, and meets all of the requirements of Final Rule (81 FR 63860) Emergency Preparedness Requirements and §§482.15 ,Condition of Participation for Hospitals.

On 03/20/18 at 10:30 AM, the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer that was identified as being site specific, non-generic Emergency Preparedness Plan containing and addressing the following elements: Development of Communication Plan; Emergency Officials Contact Information; Methods for Sharing Information; Sharing Information on Occupancy/Needs; Family Notification; Emergency Preparedness Training Program including HICS; .

The facility failed to ensure that an emergency preparedness communication plan that complies with Federal, State and local laws was developed and implemented. .

On 03/20/18 at 10:30 AM, the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer that didnt include Emergency Preparedness Plan call list containing and addressing the following elements: Names and contact information for the following: Staff, Entities providing services under arrangement, Patients' physicians, other hospitals

The facility failed to ensure that an emergency preparedness communication plan that complies with Federal, State and local laws was developed and implemented.

On 03/20/18 at 10:30 AM, the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer that didn't include Emergency Preparedness Plan call list that didn't include call lists and numbers for Federal, State, tribal, regional, and local emergency preparedness staff and or other sources of assistance

The facility failed to ensure that an emergency preparedness training program was developed and maintained, and meets all of the requirements of Final Rule (81 FR 63860) Emergency Preparedness Requirements and §§482.15.

On 03/20/18 at 10:30 AM, the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer that identified all employees had not been trained on the facilities new Emergency Preparedness Plan and Emergency Preparedness Training Program including HICS; .

The facility failed to ensure that an emergency preparedness program was developed and maintained, and meets all of the requirements of Final Rule (81 FR 63860) Emergency Preparedness Requirements and §§482.15.

On 03/20/18 at 10:30 AM, the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer and the Chief Operating Officer - Eastern Connecticut Health Network that identified that the Rockville Hospital, a hospital within the Eastern Connecticut Health Network was utilizing a integrated emergency preparedness plan that lacked a site specific communication plan; emergency officials contact information; methods for sharing information; and documentation that all hospitals within the network participated in the development of the plan

The facility did not ensure that an annual door inspection was conducted as required by LCS 8.3.3.1 and the 2010 edition of NFPA 80.

On 03/20/18 at 10:30 AM the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer and the Chief Operating Officer - Eastern Connecticut Health Network that identified that the annual door inspection was not completed by 01/01/18 as required by S&C 17-38-LSC; i.e., inspection of stairwell doors, elevator vestibule doors, elevator machine room doors, doors to Oxygen trans-filling rooms and manifold rooms, linen chute and trash chute rooms, corridor doors to linen chute and trash chutes and doors to terminus rooms for trash chutes and linen chutes was not completed until feburary 27 2018. Inspected were 65 required Fire Doors with 6 Fire doors passing, resulting in a 91% failure rate of Fire Doors with no repairs completed on the day of survey

The facility did not ensure that an annual door inspection was conducted as required by LCS 8.3.3.1 and the 2010 edition of NFPA 80.

On 03/20/18 at 10:30 AM the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer and the Chief Operating Officer - Eastern Connecticut Health Network that identified that the annual door inspection was not completed by 01/01/18 as required by S&C 17-38-LSC; i.e., inspection of stairwell doors, elevator vestibule doors, elevator machine room doors, doors to Oxygen trans-filling rooms and manifold rooms, linen chute and trash chute rooms, corridor doors to linen chute and trash chutes and doors to terminus rooms for trash chutes and linen chutes was not completed until feburary 27 2018. Inspected were 65 required Fire Doors with 6 Fire doors passing, resulting in a 91% failure rate of Fire Doors with no repairs completed on the day of survey.

The facility did not ensure that an annual door inspection was conducted as required by LCS 8.3.3.1 and the 2010 edition of NFPA 80.

On 03/20/18 at 10:30 AM the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer and the Chief Operating Officer - Eastern Connecticut Health Network that identified that the annual door inspection was not completed by 01/01/18 as required by S&C 17-38-LSC; i.e., inspection of stairwell doors, elevator vestibule doors, elevator machine room doors, doors to manifold rooms,, corridor doors to linen chute and was not completed until Feburary 27 2018. Inspected were 65 required Fire Doors with 6 Fire doors passing, resulting in a 91% failure rate of Fire Doors with no repairs completed on the day of survey.

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced "Life Safety Code".

On 03/20/18 at 10:30 AM the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer and the Chief Operating Officer - Eastern Connecticut Health Network that identified that the annual door inspection of stairwell doors, elevator vestibule doors, elevator machine room doors, doors to manifold rooms, Documentation of the required door inspection showed 65 required Fire Doors were inspected with 6 Fire doors passing, resulting in a 91% failure rate of Fire Doors with no repairs completed on the day of survey

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically, as required by section # 19.7.6 of the referenced "Life Safety Code".

On 03/20/18 at 10:30 AM the surveyor was provided with documentation by the Engineering Director-ECHN that identified that the dry pipe sprinkler system covering the Bissell Building when full flood trip tested on 06/19/17 in accordance with and NFPA 25, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems" 13.4.4.2.2.2, results of the testing indicated 2 minutes and 55 seconds of delivery of water to the test port. This time is has not been compared to the original testing times or previous times to determine if there is a problem with the system and as a rule in NFPA 13 "Standard for the Installation of Sprinkler Systems" 7.2.3.2 references 60 Seconds as a design criteria dependent on how this system was designed.

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.5 as required by the referenced LSC 19.3.7.8,

On 03/20/18 at 10:30 AM the surveyor was provided with documentation by the Hospital Emergency Management Director, Engineering Director-ECHN and ECHN Environmental Safety Officer and the Chief Operating Officer - Eastern Connecticut Health Network that identified that the annual smoke door inspection of smoke barrier doors, Documentation of the 17 required smoke barrier doors indicated 2 Smoke Barrier doors passed, resulting a 89% failure rate of Smoke Barrier with no repairs completed on the day of survey