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Based on Environment of Care Manual review, Emergency Management Manual review, and interview, it was determined the facility did not have provisions for the determination of the volume of water needed for potable and non-potable use for patients, staff, and visitors in the event of normal water supply disruption, arrangements with local utilities and suppliers for emergency water and gas supply, or specification of prioritization of the use of emergency supplies. The failed practice had the potential to affect the health and safety of patients due to the risk of dehydration in the event of a loss of the normal water supply. The failed practice had the potential to affect all patients admitted to the facility, staff, and visitors, and 37 of 37 patients on the first day (07/26/11) of the survey. The findings follow:

A. Review of the Environment of Care and Emergency Management Manuals on 07/26/11 at 1500 revealed the facility did not have documentation of arrangements with local utilities and suppliers for the emergency supply of water or gas. There was no policy for determination of the volume of water required for emergencies. There was no policy specifying methods used for prioritization and conservation of the emergency supply available for immediate use.
B. In an interview on 07/27/11 at 0930 the Plant Operation Director stated he was aware the facility did not have contracts with local utilities and water suppliers to supply the facility in the event of an emergency. He also verified the facility did not have specific methods of the use of emergency supplies and had not determined the total volume of water needed to serve patients, staff, and visitors in the event of the loss of the normal water supply.

Based on Generator Testing Log Book review and interview, it was determined the facility did not meet Life Safety Code requirements related to monthly 30 minute load exercising and weekly inspection of the generator. The failed practice had the potential to affect all patients admitted to the facility, staff, and visitors, and 37 of 37 patients on the first day (07/26/11) of the survey. See Tag K-144.