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Based on records review and interview, the Critical Access Hospital failed to ensure the Emergency Preparedness Plan was updated annually.

Finding:

On 7/15/19 between 1:45 pm and 3:30 pm, a surveyor, with the Lead EVS Associate of Housekeeping present, observed the following:

No documentation was available to establish the Emergency Preparedness Plan had been reviewed and updated from the previous year.

The surveyor confirmed these observations with the Lead EVS Associate of Housekeeping at the time of the observation.

Based on records review and interview, the Critical Access Hospital failed to ensure the provision of subsistence needs for staff and patients, weather they evacuate or shelter in place.

Findings:

On 7/15/19 between 1:45 pm and 3:30 pm, a surveyor, with the Lead EVS Associate of Housekeeping present, observed the following:

1. No documentation could be provided to verify the emergency plan includes policies and procedures to ensure adequate alternate energy sources necessary to maintain:

a.Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
b. Emergency lighting.
c. Fire Detection, extinguishing, and alarm systems.
d. Sewage and waste disposal.

The surveyor confirmed these observations with the Lead EVS Associate of Housekeeping at the time of the observation.

Based on records review and interview, the Critical Access Hospital failed to ensure a means to shelter in place for patients, staff, and volunteers who remain in the facility.

Finding:

On 7/15/19 between 1:45 pm and 3:30 pm, a surveyor, with the Lead EVS Associate of Housekeeping present, observed the following:

a. The Hospital did not provide documentation in their Emergency Preparedness Plan that would have established policies and procedures for how it would provide a means to shelter in place for patients, staff and volunteers who remain in the facility.


The surveyor confirmed this during record review and interview with the Lead EVS Associate of Housekeeping at the time of the observation.

Based on records review and interview, the Critical Access Hospital failed to ensure the role of the CAH under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials:

Finding:

On 7/15/19 between 1:45 pm and 3:30 pm, a surveyor, with the Lead EVS Associate of Housekeeping present, observed the following:

No documentation was available to verify the Emergency Preparedness Plan has included policies and procedures in its emergency plan describing the facility's role in providing care and treatment at alternated care sites under an 1135 waiver.

The surveyor confirmed these observations with the Lead EVS Associate of Housekeeping at the time of the observation.

Based on records review and interview, the Critical Access Hospital failed to ensure a list of names and contact information for the following: Staff, entities providing services under arrangement, patients physicians, other CAHs and hospitals, volunteers:

Findings:

On 7/15/19 between 1:45 pm and 3:30 pm, a surveyor, with the Lead EVS Associate of Housekeeping present, observed the following:

a. No documentation was available to verify that all required contacts are included in the communication plan.
b. No documentation was available to verify that all contact information has been reviewed and updated at least annually.

The surveyor confirmed these observations with the Lead EVS Associate of Housekeeping at the time of the observation.

Based on records review and interview, the Critical Access Hospital failed to ensure initial training in emergency prepardness policies and procedures, including prompt reporting

Finding:

On 7/15/19 between 1:45 pm and 3:30 pm, a surveyor, with the Lead EVS Associate of Housekeeping present, observed the following:

No documentation was available to establish the Emergency Preparedness Plan had been reviewed and updated from the previous year.

The surveyor confirmed these observations with the Lead EVS Associate of Housekeeping at the time of the observation.

Based on records review and interview, the Critical Access Hospital failed to participate in a full-scale exercise that is community based or facility based following the last year.

Finding:

On 7/15/19 between 1:45 pm and 3:30 pm, a surveyor, with the Lead EVS Associate of Housekeeping present, observed the following:

a. No documentation was available to establish the facility conducted a full scale exercise since May 3, 2018.


The surveyor confirmed these observations with the Lead EVS Associate of Housekeeping at the time of the observation.

Based on records review and interview, the Critical Access Hospital failed to ensure the Emergency and Standby power systems has been implemented.

Finding:

On 7/15/19 between 1:45 pm and 3:30 pm, a surveyor, with the Lead EVS Associate of Housekeeping present, observed the following:

a. No documentation was available to establish the required emergency and standby power systems meet the requirements of the facility's emergency plan and corresponding policies and procedures.
b. No documentation was available to establish the required emergency and standby power systems meet the plan for "shelter in place" and evacuation plans to establish if the facility have emergency power to maintain safe operations while sheltering in place.

The surveyor confirmed these observations with the Lead EVS Associate of Housekeeping at the time of the observation.

Based on observation and interview, the Critical Access Hospital failed to maintain 2-hour fire separation between old building and the new building in the Basement per Life Safety Code NFPA 101 (2012 Edition) 8.3.5 and 8.3.5.1.

Findings:

On 7/15/19, between 12:32 pm and 1:50 pm, surveyors with the EVS & Facilities Manager present present, observed the following:

1. At 12:32 pm, floor/ceiling 2 1/2" sprinkler pipe penetration not sealed from Medical Records Storage through 2-hour fire barrier to old building in the Basement.
2. At 12:34 pm, 2 open conduit floor/ceiling penetrations not sealed in Medical Records Storage in the Basement.
3. At 12:34 pm, pipe duct floor/ceiling penetration not sealed in Medical Records Storage in the Basement.
4. At 12:41 pm, exposed wood frame construction in floor/ceiling assembly above the sprinkler valves in Central Laundry in the Basement.
5. At 1:50 pm, exposed wood and 1 layer of 1/2" sheet rock sealing 2-hour fire barrier above fire doors (FDR-1-018A/FDR-1-018B) on Main Level.
6. At 1:50 pm, conduit wall penetration in 2-hour fire barrier above ceiling to fire doors (FDR-1-018A/FDR-1-018B) on Main Level.

The surveyors confirmed the observations with the EVS & Facilities Manager at the time of the observation

Based on observations and interview, the Critical Access Hospital failed to ensure exit discharges are continuous to a public way in 1 of 2 patient care floors per NFPA 101 7.1.6.4.

Findings:

On 7/15/19 at 1:49 pm, surveyors with the EVS & Facilities Manager present, observed the following:

1. Exit from Stairwell 2 exits on to grass, which cannot be deemed slip resistant under foreseeable weather conditions.
2. Exit from Ramp towards the old building exits on to grass, which cannot be deemed slip resistant under foreseeable weather conditions.

The surveyors confirmed the observations with the EVS & Facilities Manager at the time of the observation.

Based on observation, records review and interview, the Critical Access Hospital failed to ensure the means of egress was free from all obstructions. Records review of the health care occupancy fire safety plan did not address the relocation of wheeled equipment during a fire or similar emergency.

Findings:

On 7/15/19 between 11:00 am and 11:08 am, surveyors, with the Maintenance Employee present, observed the following:

1. At 11:00 a.m., soiled utility containers were stored in corridor in the Emergency Department

2. At 11:01a.m. Patient beds and medical equipment were stored in the corridor in the Emergency Department.

3. At 11:04 a.m. Wheel chairs were stored in the exit corridor near the ambulance entrance doors.

4. At 11:08 a.m. Paper shredding storage bins were located in the Med Surge corridor.

The surveyor confirmed these observations with the Maintenance Employee at the time of the observation.

Based on observation and interview, the Critical Access Hospital failed to ensure and maintain 11 Horizontal Sliding Doors in 2 of 2 patient care areas .

Findings:

On 7/15/19 between 11:05 am and 11:30 am, surveyors , with a Maintenance Employee present, observed the following:

1. At 11:05 am in the Emergency Department (1) of the trauma room horizontal sliding door failed to have a latch to ensure the door will not rebound.

2. At 11:30 am in the ICU Unit (3) rooms the horizontal sliding doors failed to have a latch to ensure the doors will not rebound.

The surveyors confirmed these observations with the maintenance employee at the time of the observation.

Based on observations and interview, the Critical Access Hospital failed to ensure Stairways and Smoke proof enclosures used as exits are in accordance with 7.2 of NFPA 101 Life Safety Code 2012 edition in 2 of 4 stairwells.

Findings:

On 7/15/19 between 12:39 pm and 12:47 pm, surveyors with the EVS & Facilities Manager present, observed the following:

1. At 12:39 p.m. the door located on the first floor of South stair tower did not positively latch.
2. At 12:47 pm, non-rated door and door frame in 2-hour fire rated Stairwell 4 in Central Laundry in the Basement. Current door is a 1 3/4" solid core door.
3. At 12:47 pm, flex conduit wall penetration found above the door to 2-hour fire rated Stairwell 4 in Central Laundry in the Basement.

The surveyors confirmed these observations with the EVS/Facilities Manager and Maintenance employee at the time of the observation.


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Based on observations and interview, the Critical Access Hospital failed to ensure hazardous areas penetrations were maintained in accordance with 19.3.2.1 in 15 out of 17 Hazardous Areas.

Findings:

On 7/15/19, between at 11:15 am and 2:41 pm, surveyors with the EVS & Facilities Manager present, observed the following:

1. At 11:15 am, three 3" cord penetrations through the floor/ceiling assembly of the Loading Dock in the Basement were not sealed.
2. At 11:15 am, three pipe ceiling penetrations through the floor/ceiling assembly of the Loading Dock in the Basement were not sealed.
3. At 11:15 am, ceiling penetration was sealed with pink Fiberglas and 1/2" plywood in the Loading Dock in the Basement.
4. At 11:27 am, three 2 1/2" ceiling pipe penetrations not sealed above MDP1 Electrical Panel in Generator Room 1 in the Basement.
5. At 11:27 am, 4 ceiling holes above MDP1 Electrical Panel in Generator Room 1 in the Basement.
6. At 11:29 am, floor/ceiling penetration sealed with nonrated plywood by the corridor door to Generator Room 2 in the Basement.
7. At 11:35 am, pipe wall penetration sealed with nonrated spray foam above sink in Boiler Room wall to the Loading Dock in the Basement.
8. At 11:36 am, soundproofing material installed on the ceiling of the Boiler Room in the Basement appears to be noncompliant foam board. Documentation could not be provided to indicate that this material met or exceeded 1-hour fire rating.
9. At 11:37 am, pipe and conduit penetrations throughout the entire ceiling assembly were not sealed in the Boiler Room in the Basement.
10. At 11:47 am, wall pipe penetration not sealed from Boiler Room to Freezer Storage in the Basement.
11. At 11:53 am, floor/ceiling pipe penetrations not sealed the Maintenance Shop in the Basement.
12. At 11:53 am, door protective panel attached with unapproved fasteners to bottom portion of Biohazard Storage Room 141 door in the Basement.
13. At 11:54 am, wall pipe penetration not sealed from Biohazard Storage Room 141 into Food Storage Room in the Basement.
14. At 11:55 am, soundproofing material installed on the ceiling of the Elevator Machine Room in the Basement appears to be noncompliant foam board. Documentation could not be provided to indicate that this material met or exceeded 1-hour fire rating.
15. At 11:56 am, Elevator Machine Room door in the Basement did not positively latch.
16. At 12:00 pm, open conduit wall and ceiling penetrations in Housekeeping Laundry Chute Room 33 were not sealed in the Basement.
17. At 12:04 pm, door protective panel attached with unapproved fasteners to center and bottom portions of Laundry Chute Room 33 door in the Basement.
18. At 12:06 pm, Housekeeping door 164 in the Basement did not positively latch.
19. At 12:08 pm, Training Room in the Basement listed on Life Safety Plans as Hazardous Area Storage Room 113.
20. At 12:18 pm, floor/ceiling holes sealed with non-rated foam behind the Central Storage desk in the Basement.
21. At 12:25 pm, floor/ceiling pipe penetration not sealed in Tel Room 103 in the Basement.
22. At 12:32 pm, open conduit wall penetration not sealed from Medical Records Storage Room 104 to Medical Records Office 106 in the Basement.
23. At 12:32 pm, 2 water pipe penetrations not sealed from Medical Records Storage Room 104 to Medical Records Office 106 in the Basement.
24. At 12:37 pm, fire door label painted over on corridor door to Central Laundry in the Basement.
25. At 12:37 pm, door protective panel attached with unapproved fasteners to bottom portion of Central Laundry door in the Basement.
26. At 12:46 pm, excessive lint found behind Dryer #2 in Central Laundry in the Basement.
27. At 1:42 pm, cable wall penetrations sealed with non-rated spray foam in Decommissioned Boiler Room in the Basement.
28. At 2:05 pm, Cardiovascular Ultrasound Room on the Main Level listed on Life Safety Plans as Hazardous Area Storage 1152.
29. At 2:05 pm, 45-minute door to Cardiovascular Ultrasound Room has 2 holes in the top of the door on the Main Level.
30. At 2:10 pm, 90-minute Soiled Linen 1152 door has large piece of door edge missing near the center hinge on the Main Level.
31. At 2:18 pm, unapproved hook latch obstructed Housekeeping door (FDR-1-009) from closing on Main Level.
32. At 2:33 pm, 2 ceiling tiles out of place in Clean Supply 1106 of ASU on Main Level.
33. At 2:35 pm, CT Scan Room on the Main Level listed on Life Safety Plans as Hazardous Area Storage Room Morgue.
34. At 2:40 pm, Triage on the Main Level listed on Life Safety Plans as Hazardous Area Soiled Utility 1020.
35. At 2:41 pm, top of wall sealed with non-rated spray foam from Radiology Storage 1048 to CT on the Main Level.

The surveyor confirmed these observations with the EVS & Facilities Manager at the time of the observation.

Based on observations and records review, the Critical Access Hospital failed to ensure interior finish requirements were met in two areas on two separate levels.


Findings:

On 07/15/2019, surveyors with the EVS & Facilities Manager present, observed the following:


a. 12:21 PM, wooden wall paneling was found in the Central Storage Room located in the the basement. No documentation could be provided to ensure the wall covering met interior finish requirements of NFPA 101 chapter 10/10.2.


b. 1:51 PM, wooden wall paneling was found in medical library and corridor wall outside Medical Library on the main level. No documentation could be provided to ensure the wall covering met interior finish requirements of NFPA 101 chapter 10/10.2.


The surveyors confirmed these observations with the EVS & Facilities Manager at the time of the observations

Based on record review, observation and interview, the Critical Access Hospital failed to provide sprinkler protection by an approved automatic sprinkler system in accordance with NFPA 101 Life Safety Code (2012 edition) Sections 19.3.5.3, 19.3.5.4 (1) and NFPA 13 (2010 edition) (Standard for the installation of Sprinkler Systems) Sections 11.2.1.2, 11.2.2 - 11.2.2.5.
The lack of enough water supply for the sprinkler system would jeopardize, patients, staff and visitors throughout the entire Health Care Facility.

Findings:

1. On 7-16-2019 between 1:30 pm and 3:00 pm surveyors, Systems Director, facilities management and Director of maintenance did observe the following:

a. One 9000-gallon capacity tank located in an adjacent building to the hospital. The tank gauge indicated that the tank was approximately half full of liquid (4,500 - gallons). The installation of the facilities Automatic sprinkler system was in 1967 and the 9,000 -gallon water tank was also installed at that time.

Record review of the facilities architectural Life Safety drawings indicated the facility consists of two different occupancy types in accordance with NFPA 13 2010 edition chapter 5 section 5.1, Light hazard and Ordinary hazard (Group 1). In 2006 the hospital obtained a sprinkler permit to extended sprinkler coverage throughout the basement level which included several ordinary hazard (group 1) areas. The basement consists of primarily Hazardous areas which is considered an Ordinary Hazard 1 and some business use considered Light Hazard.

b. A calculation plate for the new extended sprinkler coverage for the basement was not attached to the sprinkler riser the calculation plate would indicate the amount of water required for the extended Ordinary Hazard One coverage area.

c. There are two other potential water sources within the building, an additional 1,000-gallon water supply is located in the basement of the 1929 section of the hospital and another 25,000 gallons of water is located under the 1978 section of the hospital. The two additional water sources do not automatically feed directly to the automatic sprinkler system and cannot be accredited to the overall required water supply to the sprinkler system. The additional water supply is only available by being manually activated by facility personnel within the building during an active sprinkler event.




d. Overhead garage door in boiler room without side wall protection
e. North Stair Tower with no sprinkler protection at the basement level.
f. South Stair Tower with no sprinkler protection at the basement or second floor level.
g. Cafe Stair Tower with no sprinkler protection at the basement level.
h. No sprinkler coverage in the corridor (Waffle ceiling) leading from the 1929 business section of the hospital to the patient care area and Cafe Stair Tower.

Confirmed by Systems Director, Facilities Management and Director of Facilities at the time of the survey.


2. On 7/15/19 between 11:36 am and 1:14 pm, surveyors, with the Maintenance Employee present, observed the following:

a. At 11:36 a.m., the closet located in the back corner of Central Sterile supply, does not have sprinkler coverage.

b. At 12:58 p.m., the elevator machine room located in the basement, does not have sprinkler coverage.

The surveyors confirmed these observations with the Maintenance Employee at the time of the observation.








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Based on observations and interview, the Critical Access Hospital failed to maintain sprinkler heads by testing or replacing heads over 50 years old in accordance with NFPA 101 Life Safety Code (2012 edition) section 9.7.5, 9.7.7, 9.7.8 . NFPA 13 (2010 edition) section 26.1 and keeping sprinkler heads and valves free of obstructions in 2 of 2 patient care floors in accordance with NFPA 25 (2011 edition) section 5.1

Findings:

1. On 7/15/19 between 12:40 pm and 2:35 pm, surveyors with the EVS & Facilities Manager present, observed the following:

a. At 12:40 pm, sprinkler valves obstructed with clean laundry carts in Central Laundry in the Basement.
b. At 12:48 pm, painted sprinkler head found in wall from Stairwell 4 to Decommissioned Boiler Room in the Basement.
c. At 1:40 pm, unprotected sprinkler heads mounted at 6'3" were installed in the corridor from Central Laundry to the Decommissioned Boiler Room in the Basement.
d. At 1:40 pm, unprotected sprinkler heads mounted at 6'3" were installed inside the Decommissioned Boiler Room in the Basement.
e. At 2:14 pm, excessive dust/dirt obstructing sprinkler heads throughout ICU on Main Level.
f. At 2:20 pm, excessive dust/dirt obstructing sprinkler head in corridor outside Patient Rooms 15/16 on Main Level.
g. At 2:22 pm, stacked storage obstructing sprinkler head in Clean Supply Room 1157 on Main Level.
h. At 2:35 pm, escutcheon cap hanging on sidewall sprinkler head in outside entrance to ASU on Main Level.

The surveyors confirmed these observations with the EVS & Facilities Manager at the time of the observation.

2. Between 1:30 pm and 3:00 pm Surveyors observed and confirmed with, Director of Maintenance that no testing or replacement has been completed on any sprinkler heads older than 50 years of age.

This was confirmed with the director of Maintenance during the survey with the Systems Director and Facilities Management present.

Based on observations and interview, the Critical Access Hospital failed to ensure smoke barrier construction meet or exceed 30-minute fire rated construction in 2 of 2 patient care floors.

Findings:

On 7/15/19 between 11:20 am and 2:17 pm, surveyors with the EVS & Facilities Manager present, observed the following:

1. At 11:20 am, group of 6 flex conduit wall penetrations not sealed above the smoke barrier doors from Loading Dock to Central Storage corridor in the Basement.
2. At 11:20 am, 5 wall pipe penetrations not sealed above the right smoke barrier door from Loading Dock to Central Storage corridor in the Basement.
3. At 11:32 am, right smoke barrier door from Loading Dock to Central Storage corridor did not positively latch when released from magnetic hold open in the Basement.
4. At 12:08 pm, ceiling pipe penetration above right air handler not sealed in Mechanical AC Room 112 in the Basement.
5. At 12:24 pm, 7 wall conduit penetrations not sealed above the Tel Room 103 corridor door in the Basement.
6. At 2:17 pm, through-wall IT conduit penetration not sealed in the AHU Mechanical Room on the Main Level.

The surveyors confirmed these observations with the EVS & Facilities Manager at the time of the observation.

Based on interviews and record review the facility failed to maintain 18 of 55 fire dampers and three smoke dampers in accordance with NFPA 101 Life Safety Code (2012 edition) section 19.5.2.1 and 9.2.
Four fire dampers located on the 1st floor, 14 located at the basement level and Three smoke dampers located in the basement.
No documentation was provided at the time of the survey that any of the dampers had been fixed.

Findings:

Between 11:30 am and 12:30 pm during record review this surveyor did observe the following: Fire and Smoke damper report dated July 3, 2018 indicated that :

a. FD-1-001, FD-1-005, FD-1-021, and FD-1-022 located on the first floor failed inspection.

b. FD-B-004, FD-B-005, FD-B-008, FD-B-009, FD-B-012, FD-B-014, FD-B-017, FD-B-021, FD-B-022,
FD-B-023, FD-B-024, FD-B-025, FD-B-026, FD-B-028, failed inspection.

This was confirmed during the survey with director of maintenance, Systems Director and Facilities Management.

Based on record review the facility failed to hold fire drills on each shift every quarter in accordance with NFPA 101 Life Safety Code (2012 edition) section 19.1.4 - 19.7.1.7


Finding:

On July 15, 2019 between 11:30 and 12:00 pm it was observed that a second shift fire drill during the second quarter was not conducted.

This finding was confirmed during the survey with the Director of Maintenance.

Based on records review and interview, the Critical Access Hospital failed to ensure the central supply systems for nonflammable medical gases has been inspected annually in accordance with NFPA 101 Life Safety Code (2012 edition) section 4.6.12 and NFPA 99 Health Care Facilities Code (2012 edition) section 5.1.14.4.4


Finding:

On 7/15/19 between 11:00 am and 12:30 pm, a surveyor, with the EVS/Facilities Manager present, observed the following:

No documentation provided of an annual inspection report for the central supply systems for nonflammable medical gases.
The surveyor confirmed the with the EVS/Facilities Manager at the time of the observation.

Based on observations, the Critical Access Hospital failed to properly label medical vacuum piping in 1 area of the basement in accordance with NFPA 99 (2012 edition) section 5.1.11.1


Finding:

On 07/15/2019, surveyors with the EVS & Facilities Manager present, observed the following:


a. 11:43 AM, The section of medical vacuum piping located on the left wall of the boiler room was not labeled in accordance with NFPA 99 requirements. (required to be labeled every 20' and on each side of a wall or ceiling penetration.


The surveyors confirmed these observations with the EVS & Facilities Manager at the time of the observations

Based on observations and interview, the Critical Access Hospital failed to ensure extension cords were not used as a permanent source of power in accordance with NFPA 99 (2012 edition) in 4 of 17 Hazardous Areas, the Emergency Department Breakroom, women's locker room located near the Operating room area and in 3 of 25 patient areas.

Findings:

On 7/15/19 between 11:03 am and 1:38 pm, surveyors with the EVS & Facilities Manager present, observed the following:

1. At 11:03 a.m., a power strip was located in the Emergency Department employee break room, the strip was used to power a Refrigerator, Microwave, and toaster.
2. At 11:42 a.m., a power strip was located in the Operating room Women's locker room, the strip was used to power a microwave.
3. At 11:47 am, an extension cord is used to power an air compressor in Boiler Room in the Basement.
4. At 11:47 am, an extension cord is used to power an air dryer in Boiler Room in the Basement.
At 12:21 p.m., an extension cord was located in Room 20 on the second floor, the extension cord was used to power an air conditioner. Cord was removed during survey.

5. At 12:24 p.m. an extension cord was located in Room 19 on the second floor, the extension cord was used to power an air conditioner. Cord was removed during survey.

6. At 12:26 p.m, an extension cord was located in Room 20A on the second floor, the extension cord was used to power an air conditioner. Cord was removed during survey.

7. At 12:41 pm, an extension cord is used to power a sump pump by the sprinkler valves in Central Laundry in the Basement.
8. At 1:38 pm, an extension cord is used to power 2 sump pumps in Decommissioned Boiler Room in the Basement.

The surveyors confirmed these observations with the EVS & Facilities Manager at the time of the observation.


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