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Based on record review, the facility failed to incorporate into their Emergency Preparedness Program (EP) the policy and procedures for subsistence needs for staff and patients. The program did not have measures in place for alternate sources of energy to maintain Temperatures for the patients in the event of loss of power. This in the event of a disaster or other emergency would leave the facility and its occupants vulnerable to the hazards of the event.

The findings included:

On 03/19/2019 at 9:30am, while reviewing the facility EP, there were no policy or procedures to maintain safe temperatures in the event of a loss of the power system. The Maintenance Director verified these findings at the time it was discovered. Code of Federal Regulations (CFR) 42, Part 482.15, Requirement for hospitals.

Based on record review and interview, the facility failed to provide documentation of emergency and standby power system in their Emergency Preparedness Plan. This in the event of an emergency would leave the facility unprepared for unexpected situations that would have been addressed in the event of a power loss.

The findings included:
On 03/19/2019 at 9:30am While reviewing the facility EP, the facility was unable to provide a plan that addressed how they would keep emergency power systems operational during an emergency. An interview with the facility Administrator revealed the facility had not made any plans for cool zones or an additional generator. The current generator only runs parts of the facility and does not provide for heating, ventilation, and air conditioning (HVAC) systems for cool zones.
Code of Federal Regulations (CFR) 42, Part 482.15, Requirement for hospitals.

Based on record review with the Maintenance Director, the facility failed to provide and maintain a 5-year internal inspection of the sprinkler system, in accordance with NFPA 101(2012 edition.). Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.

The findings included:

During the Fire & Life Safety record review with the Director of Maintenance on 03/19/2019 from 830am to 1100am. It was discovered there had not been a 5-year internal inspection of the sprinkler system for the building. The Maintenance Director verified these findings at the time it was discovered. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 (2011 edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems). NFPA 101 Life Safety Code (2012 edition) 18.3.5 & 19.3.5 & 9.7.5.

Based on record review and interview with the Maintenance Director, the facility failed to provide and maintain maintenance, inspection & testing of fire doors. This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

The findings included:

During the Fire & Life Safety record review with the Director of Maintenance on 03/19/2019 from 830am 1100am, it was discovered that the facility failed to maintain records of fire door Maintenance, Inspection & Testing. The Maintenance Director verified these findings at the time it was discovered.
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
.19.7.6, 8.3.3.1 (LSC), NFPA 80 (2010 edition) 5.2, 5.2.3

Based on record review with the Maintenance Director, the facility failed to maintain the annual fuel quality test for the generator. This could result in loss of power to the emergency generator thereby endangering the patients and occupants of the facility. Proper maintenance and inspection of the generator helps to ensure proper functioning in an emergency situation.

The findings include:

During the Fire & Life Safety record review with the Director of Maintenance on 03/19/2019 from 830am to 1100am, it was found that the Fuel Quality Check for the facilities Diesel Fuel had not been done. The Maintenance Director verified these findings at the time it was discovered. NFPA 110, 8.3.3, "A fuel quality check shall be done according to ASTM Standards on a yearly basis."