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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 03/05/19 at 11:00 am, the surveyor asked Staff DD 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 DD stated the facility was unaware of the policy and they will update and revise the policies and procedures.

Based on record review and interview the facility failed to ensure annual and initial in-service training for new and existing staff, individuals providing on-site services under arrangement, and volunteers on the emergency preparedness plan for 14 (staff L, staff P, staff Q, staff R, staff S, staff T, staff U, staff V, staff W, staff X, staff Y, staff Z, staff AA, staff BB, and staff CC) of 17 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for new and existing staff, volunteers, and individuals providing on-site services under arrangement for the following staff:


Staff L with the date of hire 05/07/18 had not received initial in-service training for emergency preparedness plan.

Staff P with the date of hire 02/23/15 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff Q with the date of hire 04/23/12 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff R with the date of hire 05/10/05 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff S with the date of hire 04/23/18 had not received initial in-service training for the facility emergency preparedness plan.

Staff T with the date of hire 01/01/14 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff U with the date of hire 12/19/16 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff V with the date of hire 10/26/15 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff W with the date of hire 02/12/18 had not received initial in-service training for the facility emergency preparedness plan.

Staff X with the date of hire 01/24/11 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff Y with the date of hire 01/02/18 had not received initial in-service training for the facility emergency preparedness plan.

Staff Z with the date of hire 08/30/02 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff AA with the date of hire 05/22/17 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff BB with the date of hire 04/25/16 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff CC with the date of hire 10/24/16 had not received initial or annual in-service training for the facility emergency preparedness plan.

The emergency preparedness training records for initial and or annual in-service do not exist for Staff L, Staff P, Staff Q , Staff R, Staff S, Staff T, Staff U, Staff V, Staff W, Staff X, Staff Y, Staff Z, Staff AA, Staff BB and Staff CC.

On 03/04/19 at 01:15 pm the surveyor requested Mercy Hospital Kingfisher training transcripts of new and existing staff, volunteers, individuals providing on-site services under arrangement.
On 03/05/19 at 2:40 pm following review of the requested documentation, the surveyor explained to Staff DD and Staff E that no evidence of initial and/or annual training documentation existed for some staff training on emergency preparedness. The transcripts provided to the surveyor did not reflect courses completed. The surveyor asked Staff E and Staff DD for the facility process for training on emergency preparedness. Staff E stated the facility provides both initial and annual training for employees related to Emergency Preparedness, sign-in sheets was not provided. The surveyor was unable to verify that documentation existed for emergency preparedness. The emergency preparedness documentation did not exist for some staff.


Based on record review and interview the facility failed to demonstrate education and instruction to staff of a community based exercise, tabletop exercise, or full-scale exercise to demonstrate staff knowledge of emergency procedures.

On 03/05/19 at 11:38 am Staff DD was asked to provide documentation such as a sign-in sheet, meeting minutes, to verify staff received training on drills or exercises dated July 18, 2018 and November 15, 2018 completed by the facility. Staff DD stated the facility did not have sign-in sheets for the exercises the staff participated in or trained for. The surveyor stated, CMS requires facilities to be able to demonstrate documentation exists for training, drills and exercises in order to verify staff knowledge of emergency procedures, and to identify gaps and areas for improvement. The document did not exist to verify staff received in-service training.

Based on observation and interview the facility failed to ensure hazardous areas were free from penetrations.

Findings:

On 03/05/19 at 10:37 am four penetrations were observed in the ceiling of the IT room.

On 03/05/19 at 10:59 am a wooden door wedge was observed holding the door in an open position to where medical records were being stored.

On 03/05/19 at 10:59 am Staff E was asked why the door wedge was in place on the hazardous door to medical records storage. Staff E stated it was due to staff accessing the area frequently but will remove it to order a magnetic lock which is a compliant hold open device.

On 03/05/19 at 11:05 am one penetrations was observed in the data room in the sleep lab.

On 03/05/19 at 11:05 am the surveyor asked staff E what happened to the ceiling and sleep lab. Staff E stated the contractors come into the facility and do not fill the penetrations after they complete their work. Staff E stated he will get the penetrations properly fire stopped.

Based on record review, observation and interview the facility failed to ensure manometers were installed on HVAC units serving the operating rooms/procedure rooms, and ASHRAE 170-2008 ventilatory standards were being followed as required.

Findings:

Record review showed the facility did not have manometer readings documentation for the changing of air filters of the HVAC systems serving the surgical suite operating rooms/procedure rooms to ensure ASHRAE 170-2008 ventilatory guidelines were being followed.

On 03/05/19 at 10:15 am the surveyor asked staff E for the manometer readings documentation. Staff E stated the architect did not design the HVAC system serving the operating rooms with manometers.

Record review showed the semi restrictive corridor in the surgical suite was not shown to be included on the Harrison Orr Test and Balance 12/10/18 annual inspection report.

On 03/06/19 at 11:30 am the semi restrictive area of surgical suite were observed to contain metal shelves storing sterile supplies which require positive ventilation.

On 03/06/19 at 11:30 am the surveyor asked staff E if the semi restrictive area was included on the test and balance inspection report. Staff E stated the area was not included but will be added.

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 fire drills did not document a transmission of a fire alarm signal.

On 03/05/19 at approximately 2:18 pm the surveyor stated to staff E to show where the documentation of the transmission of a fire alarm signal was located in the documentation. Staff E stated that bit of information is not documented on the fire drill forms but will be.