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Based on record review and interview, the hospital failed to ensure the emergency preparedness plan was reviewed, and updated as required.

Findings:

Record review of the emergency preparedness plan showed the last time the facility plan was reviewed and updated was 11/07/17.

On 07/22/19 at 10:00 am the surveyor asked the Radiology Manager (RM)/ Emergency Prepardness (EP) Contact if there was a more recent update for the facility's emergency prepardness plan. RM/EP Contact stated no.

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 07/22/19 at 10:00 am the surveyor asked the Radiology Manager/Emergency Prepardness (EP) Contact 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. The RM/EP Contact stated the facility was unaware of the policy.

Based on record review and interview the facility failed to ensure development of the facility emergency preparedness communication plan.

Findings:

Record review of the emergency preparedness plan showed it did not contain a communication plan as required.

On 07/22/19 at 11:17 am the surveyor asked the Radiology Manager/Emergency Prepardness (EP) Contact for the emergency preparedness communication plan. The RM/EP Contact stated it has not been developed as the position has been turned over to him and he is getting the EP program organized.

Based on record review and interview the facility failed to ensure the facility had written policies/procedures for primary/alternate means for communication which was also included in the facility emergency preparedness communication plan as required.

Findings:

Record review of the emergency preparedness plan showed it did not contain a communication plan as required nor any outline of the facility's primary/alternate means for communication to use during an emergency event/disaster.

On 07/22/19 at 11:17 am the surveyor asked the Radiology Manager/Emergency Prepardness (EP) Contact for the emergency preparedness communication plan which was to include the primary and alternate forms the facility has chosen to use in the event of an emergency event. The RM/EP Contact stated first they would use walkie-talkies. The surveyor asked the RM/EP Contact where that is written down or in a facility policy and they stated that it is not written down anywhere.

Based on record review and interview the facility failed to ensure training and testing by developing and maintaining an emergency preparedness (EP) training and testing program that is based on the EP plan, facility EP policy and procedures, and the facility communication plan all of which must be reviewed and updated at least annually as required.

Findings:

Record review showed the facility did not have a EP training program which included the facility EP plan or a communication plan as required as it does not exist.

On 07/22/19 at 3:38 pm the surveyor asked the Radiology Manager/Emergency Prepardness (EP) Contact to see the EP training curriculum and he stated their EP training is NIMS/ICS. The surveyor asked the RM/EP Contact if they provided the facility EP plan as a part of their initial training and they stated no. The surveyor explained the EP training is to include the facility EP plan which includes the facility communication plan which is to be given as an initial training to all new employees. There is also ongoing annual EP training that is to be given and is to also be documented.

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

Findings:

On 07/22/19 at 2:32 pm the surveyor observed a padlock on the central supply door and on the dining room door. The surveyor also observed deadbolt locks on several corridor doors which would take two actions to gain access to the egress corridor pathway.

On 07/22/19 at 2:32 pm the surveyor asked the Director of Maintenance (DOM) why there were padlocks on the central supply door and dining room door. The DOM stated those padlocks had always been there and they were there for added security to be the of their understanding. The surveyor explained to be in compliance the lock would have to be able to be defeated with one action from the egress side of the door. The DOM 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 each exit discharge had emergency generator powered or battery powered backed-up emergency lighting installed as required.

Findings:

On 07/22/19 at 1:20 pm each of the seven designated exit discharges from the facility were observed to have lighting fixtures on normal power.

On 07/22/19 at 2:38 pm the surveyor asked the Director of Maintenance (DOM) at each of the seven exits if they were on emergency generator power. The DOM stated they were not certain if each of the seven was on the generator. The surveyor explained that they could either wire each of the existing lighting fixtures to the generator or install battery powered backed up emergency lighting to be in compliance.

Based on obsevation and interview the facility failed to ensure corridor doors where held open with approved hold open devices as required.

Findings:

On 07/22/19 at 4:41 pm the surveyor observed the nurses locker room corridor door with an installed metal hold open device, the pharmacy office corridor door was observed to have a wooden chock holding the door open which in the event of a fire would not allow the door to close so fire/smoke would spread throughout the facility. The survyeor observed two self-closers which were uninstalled in the board room.

On 07/11/19 at 4:45 pm the surveyor asked the Director of Maintenance (DOM) why staff were allowed to use metal and wooden chocks to hold open corridor doors. The DOM stated he did not know why staff had placed the wooden chocks on the doors but will explain to them they are not allowed.

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 2019, and 2018 did not document a transmission of a fire alarm signal for every fire drill completed.

On 07/22/19 at 1:07 pm the surveyor stated to the Director of Maintenance (DOM) the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. The DOM 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 2018 were not completed and the documentation did not exist.

On 07/22/19 at 9:42 am the surveyor asked the Director of Maintenance for the annual fire rated door assembly inspections. The DOM stated the inspection was not completed for 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 07/22/19 at 9:35 am the surveyor asked the Director of Maintenance for the EES and Medical Gas building system risk assessments. The DOM stated that they are not familair with the requirement but will complete it now that they are.

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 2019, 2018, 2017, 2016 and 2015.

On 07/22/19 at 3:56 pm the medical gas systems annual inspections were requested for 2019, 2018, 2017, 2016, and 2015 and were not available as they do not exist.

On 07/22/19 at 3:56 pm the surveyor asked the Director of Maintenance (DOM) why the medical gas inspections were not completed. The DOM stated that they do not know it was a requirement.

On 07/23/19 at 12:15 pm the surveyor asked the Chief Executive Officer (CEO) if they were able to find any annual medical gas inspection reports. The CEO stated that they looked back ten years and did not find where they had any inspection or contracts for medical inspections to be done.

Based on record review, and interview the facility failed to ensure annual impedance testing of patient care related electrical receptacles as required.

Findings:

Record review showed the facility did not have the annual impedance testing of the patient care related electrical receptacles.

On 07/22/19 at 10:43 am the surveyor asked the Director of Maintenance (DOM) for the annual impedance testing inspection of patient care related electrical receptacles for patient treatment areas. The DOM stated they have not completed the testing but will get it scheduled and done.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing, annual two hour load bank testing, and 36 month, four hour load bank testing was conducted on the emergency generator as required.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2016, 2017 and 2018 as the documents do not exist.

Record review showed the facility has not conducted annual two hour load bank testing for 2018, 2017, 2016 and 2015 as the documents do not exist.

Record review showed the facility has not conducted a 36 month, four hour load bank test on the emergency generator as the document does not exist.

On 07/22/19 at 1:52 pm the surveyor asked the Director of Maintenance (DOM) to provide the following: annual emergency generator fuel quality testing documentation for 2016, 2017 and 2018; Annual load bank testing for 2018, 2017, 2016,and 2015; and the last thirtysix month four hour load bank test. The DOM stated the tests the surveyor requested were not done so the documents are not available.

Based on observation and interview the facility failed to ensure wiring complied to NFPA 70/NFPA 99/UL standards as required.

Findings:

On 07/22/19 at 12:42 pm the surveyor observed a white residential extension cord located at the front entrance waiting area.

On 07/22/19 at 12:42 pm the surveyor asked the Director of Maintenance (DOM) why the white extension cord was at the front waiting area. The DOM stated that they would remove it and make sure it was not used again.

On 07/22/19 at 12:45 pm the surveyor observed a microwave plugged into a power tap in the break area.

On 07/22/19 at 12:45 pm the surveyor asked the DOM why the microwave was plugged into a power tap. The DOM stated there is not enough outlets in the break area but will make sure staff are told.

On 07/22/19 at 2:23 pm the surveyor observed a multiplug plugged into a power strip, and an extension cord daisy chained into a power tap in the Chief Executive Officer's (CEO) office.

On 07/22/19 at 2:23 pm the surveyor asked the DOM why the several electrical issues in the CEO's office haven't been corrected. The DOM stated they did not know.

Based on observation and interview, the facility failed to ensure all patient care related electrical equipment was tested and inspected before being placed into service.

Findings

On 07/22/19 at 2:29 pm the surveyor observed a blood bank refrigerator to have a expired inspection sticker showing the due date for reinspection was 05/2019.

On 07/22/19 at 2:29 pm the surveyor observed a specimen refrigerator to have a expired inspection sticker showing the due date for reinspection to be 05/2019.

On 07/22/19 at 4:05 pm the surveyor observed a Harvey Hydroclave MC10 to have a expired inspection sticker showing the due date for reinspection to be 05/2019.

On 07/22/19 at 4:05 pm the surveyor asked the Director of Maintenance (DOM) what the process is for their biomedical vendor in regards to maintain current inspections for their biomedical equipment. The DOM stated they place inspection stickers on the equipment which indicates the equipment is current and must have missed those.

Based on observation and interview the facility failed to ensure proper storage of the facility's liquid oxygen manifold reserve containers as required.

Findings:

On 07/22/19 at 4:15 pm the surveyor observed seven liquid oxygen VGL containers unsecured at the facility oxygen manifold along with round green plastic caps covering the floor. The surveyor also observed four gaseous oxygen bottles unsecured stored in oxygen manifold room.

On 07/22/19 at 4:15 pm the surveyor asked the Director of Maintenance (DOM) why the oxygen was unsecured. The DOM stated they would get the oxygen secure as soon as they can.