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Based on record review and interview, the hospital failed to ensure development, maintenance, and annual review of a facility-based community-based risk assessment using an all hazards approach as required.

Findings:

Record review of the emergency preparedness plan showed the facility did not annually maintain and review the facility-based and community-based risk assessments that utilized an all hazards approach. An annual risk assessment for the facility emergency preparedness plan did not exist.

On 07/11/19 at 01:17 pm, the surveyor asked Staff F for written documentation of the facility's risk assessments and associated emergency preparedness strategies. Staff F stated the facility was unaware of this requirement. The documentation did not exist. Staff F stated the facility is in process of updating their emergency preparedness plan to ensure compliance with risk assessment component.

Based on record review and interview the facility failed to ensure policy and procedures were established to address the use of volunteers in an emergency.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the use of volunteers in an disaster.

On 07/11/19 at 1:38 PM, the surveyor requested documentation for policy and procedures for volunteers. Staff F stated the facility did have a policy in place to address volunteers roles and responsibilities during a disaster. The policy did not exist. Staff F stated the facility is in process of updating and revising policies to ensure compliance with the emergency preparedness plan and development of volunteer policy and procedures.

Based on record review and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with section 1135 of the act in provision of care and treatment. The facility lacked a policy.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster.


On 07/11/19 at 02:50 pm, the surveyor asked Staff F if the facility established 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 F stated the facility was in process of updating policies to ensure compliance with the 1135 waiver policy. The document did not exist.

Based on observation and interview the facility failed to ensure egress doors could be opened with one action as required.

Findings:

On 07/11/19 at 3:11 pm the surveyor observed deadbolt locks on several corridor doors which would take two actions to gain access to the egress pathway.

On 07/11/19 at 3:11 pm the surveyor asked staff S why there were deadbolts on several of the corridor doors which would take two actions to open. Staff S stated it had always been there and they did not really know why the deadbolts were installed. Staff S stated they would have them changed with a lock that will only take one action to open the door to be in compliance.

Based on observation and interview the facility failed to ensure corridor doors in the facility where held open by an approved hold-open device complying with 7.2.1.8.2 that automatically close upon activation of the fire alarm system, local smoke detectors, automatic sprinkler system or a loss of electrical power.

Findings:

On 07/11/19 at 1:46 pm the surveyor observed two kitchen doors on the corridor held open with plastic chocks.

On 07/11/19 at 1:46 pm the surveyor asked staff S why the kitchen corridor doors had chocks holding them open. Staff S stated he did not know why the chocks were there but will remove them.

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 07/11/19 at 1:22 pm one K class fire extinguisher and one ABC class fire extinguisher was observed in the kitchen with no placards posted next to them to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 07/11/19 at 1:22 pm Staff S stated they would get the appropriate placard(s) for each of the fire extinguishers which 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 obsevation and interview the facility failed to ensure corridor doors did not have penetrations cut into them which would allow fire and smoke to spread into the protected emergency egress pathway.

Findings:

On 07/11/19 at 4:41 pm the surveyor observed eight corridor doors with vent holes cut into the bottom half of each door with a metal vent covering the cut out area of the door.

On 07/11/19 at 4:45 pm the surveyor asked staff S why the corridor doors had penetrations cut into them with metal vents installed. Staff S stated he did not know and the doors had been that way since he just recently started. Staff S stated he will repair the doors to seal the penetrations.

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 facility fire drills for 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.

On 07/11/19 at 3:54 pm the surveyor stated to Staff S the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff S 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 and 2018 were not completed and the documentation did not exist.

On 07/11/19 at 2:33 pm the surveyor asked Staff S for the annual fire rated door assembly inspections. Staff S stated the inspection was not completed for 2017, 2018 and the documentation does 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. They do not exist.

On 07/11/19 at 2:35 pm the surveyor asked staff S for the EES and Medical Gas building system risk assessments. Staff S stated he was not aware of the requirement but would ensure they would be completed.

Based on record review and interview the facility failed to ensure the facility medical gas systems were inspected annually as required.

Findings:

Record review showed the facility did not complete annual medical gas inspections for 2016, 2017, 2018 or 2019.

On 07/11/19 at 3:56 pm the medical gas systems annual inspections were requested for 2016, 2017, 2018 and 2019 and were not provided as they do not exist.

On 07/11/19 at 3:56 pm the surveyor asked staff S why the medical gas inspections were not completed. Staff S stated that they do not know why the previous staff person did not do them but they will get them scheduled to be completed.

Based on record review and interview the facility failed to ensure impedance testing/maintenance to hospital grade electrical receptacles in patient care areas were placed on a preventative maintenance program based on intervals defined by documented performance data as required.

Findings:

Record review showed the facility did not complete impedance testing for patient care related electrical receptacles as required.

On 07/11/19 at 11:27 am the surveyor asked staff S why the impedance testing has not been completed. Staff S stated he was not totally familiar with all of the requirements for life safety code since he just recently started in his position but will get the testing scheduled to be done with their electrical contractor.

Based on record review and interview the facility failed to ensure monthly and yearly emergency generator load bank tests were completed as required.

Findings:

Record review showed the monthly and yearly generator load banks were not conducted for 2017, or 2018.

On 7/11/19 at 1:23 pm the surveyor asked staff S why the emergency generator has not been exercised monthly and yearly as required. Staff S stated the person who was in the position did not do a good job and they were let go, and he just recently took over. Staff S stated they will do what they need to monthly and yearly for the load bank tests for the generator to be completed as required.