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Based on record review and interview the facility failed to ensure the emergency preparedness plan was based on an all hazards approach as required.

findings:

Record review showed the facility HVA internal and external emergencies were not included in the facility's emergency preparedness plan as required to ensure it was an all hazards approach as required.

On 11/15/21 at 11:32am the surveyor asked staff M why there were no HVA specific internal or external policies/procedures of hazards specific to the facility addressed in the facility's current emergency preparedness plan. Staff M stated that Jackson County Memorial Hospital has taken the facility under their management and will be making corrections to the facility's emergency preparedness plan to include an all hazards approach to meet compliance.

Based on record review and interview the hospital failed to ensure facility patient population demographics was included in the emergency preparedness plan as required.

Findings:

Record review of the emergency preparedness plan showed the facility did not develop or identify the facility's patient populations that would be at risk during an emergency event.


On 11/15/21 at 10:17 am the surveyor asked Staff M if the facility identified and addressed the types of services the facility would be able to provide in an emergency. Staff M stated the facility was unaware the emergency plan needed to address the patient populations that would be at risk during an emergency event.

Based on record review and interview, the hospital failed to ensure the emergency preparedness policies and procedures identified a system of medical documentation preserving the patient information, protecting confidentiality of patient information.

Findings:

Record review of the emergency disaster plan policies and procedures revealed the facility did not establish and maintain a medical record documentation system in order to preserve patient information, protects the confidentiality and secure patient information.

On 11/15/21 the surveyor asked Staff M if the facility had a plan in place to address if an disaster would affect the facility and evacuation occurs how the patients medical records
would ensure confidentiality was protected and secured. Staff M stated the medical records will be evacuated with the patients. The surveyor informed Staff M the facility policies and procedures should be in compliance with the Health Insurance Portability and Accountability Act. Staff M stated they would develop a policy and procedure to ensure compliance for protection of patient records and portability.

Based on record review and interview the facility failed to ensure the communication plan contained a specific primary and alternative form of communication as required.

Findings:

Record review showed the facility emergency preparedness plan listed multiple forms of communication but did not delineate which specific ones were the primary or alternate form of emergency communication in the event a disaster occurred.

On 11/15/21 at 1:34pm the surveyor asked staff M to show them the primary and alternative forms of emergency communication in the event of a local or facility disaster was to occur. Staff M reviewed the facility emergency preparedness plan and agreed the plan showed several general forms of emergency communication. Staff M stated they will write in specific primary and alternative forms of emergency communication to be in compliance.

Based on record review and interview the facility failed to ensure the facility's communication plan included information about the facility's needs, it's ability to provide assistance as required.

Findings:

Record review showed the facility's communication plan did not include information on occupancy or the facility's potential needs in the event of an emergency event.

On 11/15/21 at 11:39am the surveyor asked staff M to show them where in the emergency preparedness plan the information on occupancy/needs was in order to comply with CMS E34 tag. Staff M stated it was not included but can be easily added.

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.

Findings:

Record review of the facility emergency preparedness initial training documentation did not show any facility emergency preparedness policies were included as required.

On 11/15/21 at 11:38 am the surveyor asked Staff M to show them where the facility's emergency preparedness policies and procedures are in the new employee orientation. Staff M stated they reviewed the program and found it did not include the facility's emergency preparedness policy's and procedures. Staff M stated they will correct this to be in compliance.

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

Findings:

On 11/15/21 at 4:17pm the surveyor observed deadbolt locks on four patient room doors and several other emergency egress corridor doors in addition to barrel latches on the bathroom doors of the patient rooms.

On 11/15/21 at 4:17pm the surveyor asked staff M why there were deadbolts on the corridor doors and slide latches on the patient room bathroom doors which would take two actions to open. Staff M stated the deadbolts and slide latches were on the doors within the facility since he started working there and he did not know they were not allowed. Staff M 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 record review and interview the facility failed to ensure annual test and balance inspections were competed to ensure compliance with ASHRAE 170-2008 ventilatory standards as required.

Findings:

Record review showed the facility did not complete annual test and balance inspections to ensure ASHRAE 170-2008 ventilatory standards were being followed for two isolation rooms.

On 11/15/21 at 1:56 pm staff M was asked for the annual test and balance inspection reports for 2020, 2019, and 2018. Staff M stated after looking for the documentation they could not find it so it was not done.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 11/16/18 at 9:40 am a K class fire extinguisher was observed in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher.

On 11/16/18 at 9:40 am Staff M stated he would get with their fire service vendor to get the appropriate placard(s) for each of the fire extinguihsers that are installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review and interview the facility failed to ensure the automatic sprinkler systems are inspected, and maintained in accordance with NFPA 25 as required.

Findings:

Record review showed the facility did not have a sprinkler inspection for

On 11/15/21 at 12:17pm several sprinkler heads over the large freezers in the kitchen were observed to have lint on them.

On 11/15/21 at 12:17pm the surveyor stated condition of the sprinkler heads should be included on the sprinkler inspections. Staff M stated he has only been in his position for three weeks but would make sure sprinkler heads are on the check list for their fire service vendor from this point on.

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, 2019, and 2020 were not completed.

On 11/15/21 at 12:35pm the surveyor asked Staff M for the annual fire rated door assembly inspections. Staff Mstated the inspections was not completed for 2018, 2019, and 2020.

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.

On 11/15/21 at 11:23am the surveyor asked Staff M for the EES and Medical Gas building system risk assessments also known as the building system risk assessment. Staff M stated they will get the building system risk assessment done for the facility to be in compliance.

Based on record review and interview the facility failed to ensure the facility medical gas systems were inspected/maintained annually as required.

Findings:

Record review showed the facility did not complete annual medical gas inspection testing for 2018, 2019, 2020.

On 11/15/21 at 2:27pm the medical gas systems annual inspections/testing were requested for 2018, 2019, and 2020 and were not provided.

On 11/15/21 at 2:28pm the surveyor asked staff M why the medical gas inspection/testing were not completed. Staff M stated that they had some work done to the medical gas system by Apex their vendor but will get it scheduled.

Based on record review and interview the facility failed to ensure impedance testing/maintenance to hospital grade electrical receptacles in patient care areas were placed on a preventative maintenance program based on intervals defined by documented performance data as required.

Findings:

Record review showed the facility did not complete impedance testing for patient care related electrical receptacles for 2019, 2020 and 2021 as required.

On 11/15/21 at 11:27am the surveyor asked staff M why the impedance testing has not been completed. Staff M stated they did not know but will get the impedance inspection testing scheduled.

Based on record review and interview the facility failed to ensure the emergency generator testing was completed.

Findings:

Record review showed the following not to have been completed: monthly load bank testing for 2018, 2019, and 2020.

On 11/15/21 at 1:52 pm Staff M was asked to provide the emergency generator log documentation for 2015, 2016 and 2017. Staff M stated the generator logs he already gave the surveyor was all he could find.

Based on observation and interview the facility failed to protect a hazardous area oxygen storage room with fire rated construction as required.

Findings:

On 11/16/21 at 10:47am the surveyor observed 14 E sized oxygen cylinders stored in a non-rated corridor closet. Any room housing oxygen over 3000 cubit feet is to have in non-sprinklered facility two hour fire rated protection with the light switch installed over five and a half feet from the floor with the lighting fixture enclosed as required.

On 11/16/21 at 10:47am the surveyor asked staff why the 14 E oxygen tanks were stored together in a non-protected closet. Staff M stated they will remove the number of E tanks to be under the 3000 cubit feet in order to be in compliance.