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Based on review of the Clinch Memorial Hospital's Emergency Preparedness Plan and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z.

This could place all patients at risk in the event of emergency

The findings include:

During a review of the facility's Emergency Preparedness Plan on 09/30/2019 between 1:15 pm and 4:56 pm, it was noted that the facility's Emergency Preparedness Plan had not identified the role of the ASC 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; and did not meet the requirements of Appendix Z.

These findings were confirmed by Staff M at the time of discovery.

Based on review of the Clinch Memorial Hospital's Emergency Preparedness Plan and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z.

This could place all patients at risk in the event of emergency

The findings include:

During a review of the facility's Emergency Preparedness Plan on 09/30/2019 between 1:15 pm and 4:56 pm, it was noted that the facility's Emergency Preparedness Plan had not developed and maintained an EP communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually; and did not meet the requirements of Appendix Z.

These findings were confirmed by Staff M at the time of discovery.

Based on review of the Clinch Memorial Hospital's Emergency Preparedness Plan and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z.

This could place all patients at risk in the event of emergency

The findings include:

During a review of the facility's Emergency Preparedness Plan on 09/30/2019 between 1:15 pm and 4:56 pm, it was noted that the facility's Emergency Preparedness Plan did not have primary and alternate means for communicating with the hospital staff, Federal,
State, tribal, regional, and local emergency management agencies.

These findings were confirmed by Staff A at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that the smoke barriers were constructed to a 1/2 hour fire resistance rating and would prevent the passage of smoke. This could place all residents at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on 09/30/2019 between 1:15 pm and 4:56 pm, observation revealed that above ceiling two holes had been placed through the smoke barrier wall located above the double doors near the Employee Entrance / Clock-In area, and a one blue wire and one black wire was placed through one of the holes and the other hole was empty. These penetrations had not been sealed with properly rated materials.

Ref: 2012 NFPA 101 Chapter 19, Section 19.3.7.3; Chapter 8 Sections 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3 and Chapter 4, Section 4.6.12.1

These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to conduct and properly document fire drills. This could place all residents at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on 09/30/2019 between 1:15 pm and 4:56 pm, observation revealed that a fire drill was not conducted and documented during 1st shift of the 3rd quarter of 2019.

Ref: 2012 NFPA 101, 19.7.1.4 through 19.7.1.7

These findings were confirmed by Staff M at the time of discovery.