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Based on record review and interview, it was determined the facility failed to develop and maintain a current Emergency Preparedness program in accordance with 42 CFR 483.73 which is reviewed and subsequently updated annually. Lack of a current comprehensive emergency program has the potential to hinder resident access to continuing care during a disaster. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of the provided emergency plan, policies and procedures, revealed the facility had not developed a current policy or emergency plan in accordance with the standard. The provided emergency plan was an incomplete draft that was still being developed. When asked, the Director of Nursing stated the facility was working on developing a current comprehensive plan.

a. Refer to E 0007 as it relates to the facility resident population; continuation of operations; succession planning.

b. Refer to E 0009 as it relates to a process for cooperation and collaboration with local, tribal, regional, State, and Federal Emergency Preparedness Officials' efforts to maintain an integrated response during a disaster.

c. Refer to E 0015 as it relates to the policies and procedures for the subsistence needs for residents and staff members during a disaster.

d. Refer to E 0018 as it relates to the policies and procedures for tracking residents and staff in the event of a disaster.

e. Refer to E 0022 as it relates to the policies and procedures for residents and staff who remain in the facility and shelter in place.

f. Refer to E 0024 as it relates to the facility use of volunteers

g. Refer to E 0025 as it relates to the collaborative arrangements of the facility with other care providers in the event of limitations and/or cessation of operations.

h. Refer to E 0026 as it relates to the facility role under 1135 waiver as declared by the Secretary and the provision of care at an alternate site identified by emergency management officials.

i. Refer to E 0030 as it relates to the required contact information in the Communication Plan.

j. Refer to E 0034 as it relates to the facility's means of providing information of occupancy needs and its ability to provide assistance during an emergency.

k. Refer to E 0037 as it relates to the emergency training program and the staff knowledge of emergency procedures.

l. Refer to E 0039 as it relates to the required exercises and testing requirements of the emergency preparedness plan.

m. Refer to E 0041 as it relates to the required written plan for Emergency and standby power systems.

The cumulative effect of these systemic deficient practices, impeded the facility's ability to meet the emergency preparedness standard(s) and the potential needs of the patients during a disaster.

Reference:
42 CFR 483.73 (a)

Based on record review and interview, it was determined the facility failed to provide current policies and procedures which addressed the type of services the hospital has the ability to provide in an emergency, including continuity of operations with staff succession planning. Failure to provide updated policies, procedures and succession plan, potentially hinders continuation of patient care during an emergency. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of the provided emergency plan, policies and procedures, revealed the facility had not specified what types of services they could provide in the event of an emergency. The provided emergency plan was an incomplete draft that was still being developed. When asked, the Director of Nursing stated the facility was still working on the scope of services they could provide to the community in the event of a disaster.

Reference:
42 CFR 483.73 (a) (3)

Based on record review and interview, it was determined the facility had not contacted other entities and emergency responders within their community to promote an integrated response to emergency events. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings include:

Review of the facility emergency plan on January 8, 2018 from 11:00 AM to 4:00 PM, revealed the facility failed to collaborate with local, tribal, regional, State, and Federal officials in an effort to maintain an integrated response. When asked, the Director of Nursing stated the facility had not yet reached out to any of these organizations or participated in any of the planning or training they provide.

Reference:

42 CFR 483.73 (a) (4)

Based on record review and interview, it was determined the facility failed to develop and maintain current policies and procedures to provide subsistence needs of patients and staff should they need to evacuate or shelter in place during a disaster. Lack of subsistence policies limits the facility's ability to provide continuing care and services for patients during an emergency. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of the emergency preparedness plan did not indicate current policies were available demonstrating the ability of the facility to provide for subsistence of both patients and staff in the event of evacuation or shelter in place during a disaster. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (b) (1)

Based on record review and interview, it was determined the facility failed to provide a current policy for tracking of on duty staff and sheltered patients during an emergency, or if relocated, a policy for documentation of the receiving facility or other location for those relocated individuals. Lack of a tracking policy has the potential to hinder the facility's ability to provide care and continuation of services during an emergency. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of provided records, policies and procedures failed to demonstrate the facility had in place a system to track the location of on-duty staff and sheltered residents during an emergency. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (b) (2)

Based on record review and interview, it was determined the facility failed to provide a current policy and procedure for sheltering in place which can subsequently be reviewed annually. Lack of a current policy and procedure for sheltering in place has the potential to leave patients and staff without resources to continue care during an emergency. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of provided policies, procedures and emergency planning records, failed to demonstrate current and annually reviewed policies and procedures for sheltering in place. Documents provided were a draft and were incomplete. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (b) (4)

Based on record review and interview, it was determined the facility failed to develop, document and maintain current emergency policies, procedures and operational plans for the use of volunteers to address surge needs during an emergency. Lack of current plans and policies for the use of volunteers has the potential to hinder the facility's ability to care for patients and provide continuation of care during a disaster. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of provided policies, procedures and emergency preparedness records failed to demonstrate a current plan, which addressed the use of volunteers, or integration of State and Federally designated health care professionals to address surge needs during an emergency. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan including policies and procedures for addressing surge needs and the use of volunteers.

Reference:
42 CFR 483.73 (b) (6)

Based on record review and interview, it was determined the facility failed to document a current plan for collaborative arrangements between the facility and other health care providers. Without current policies for collaboration with other health care providers to accommodate for limitations and for the cessation of operations, the facility is potentially left without support services to continue care during an emergency. This deficient practice could potentially affect 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of provided policies, procedures and emergency plans, failed to indicate a current plan for collaboration with other health care providers. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (b) (7)

Based on record review and interview, it was determined the facility failed to document a current plan for the facility role under an 1135 waiver as declared by the Secretary and the provisions of care at an alternate site if identified by emergency management officials. Failure to plan for alternate means of care and the role under an 1135 waiver has the potential to limit facility options during an emergency. This deficient practice could potentially affect 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of the provided policies and procedures revealed the facility did not have a current policy or procedure that addressed the facility role during a disaster event. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (b) (8)

Based on record review and interview, it was determined the facility failed to document a communication plan with all required elements. Failure to have a communication plan complete with names and contact information, has the potential to hinder both internal and external emergency response by personnel. This deficient practice had the potential to affect 2 patients, staff and visitors on the dates of the survey.

Findings Include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of the facility emergency plan revealed the communication portion of the plan failed to provide the names and contact information for entities providing services under arrangement, patient's physicians, or volunteers. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (c) (1)

Based on record review and interview, it was determined the facility failed to document a current plan for sharing information on needs, occupancy and its ability to provide assistance with emergency management officials. Lack of a current plan for providing information to emergency personnel on the facility's needs and abilities to provide assistance during an emergency has the potential to hinder response assistance and continuation of care of patients. This deficient practice could potentially affect 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of provided policies, procedures and emergency plans revealed no indication of what method the facility would use to share information on its needs or capabilities with emergency management officials. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (c) (7)

Based on record review and interview, it was determined the facility failed to provide a current emergency prep training program. Lack of a training program on the emergency preparedness plan and policies for the facility, has the potential to hinder staff response during a disaster. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings include:

On January 8, 2018 from 11:00 AM to 4:00 PM, review of the facility documentation revealed no written training plan was included in the emergency plan for training staff on the emergency preparedness policies and procedures. There was also no documentation that initial training for all new and existing staff, individuals providing services under arrangement or volunteers had taken place. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (d) (1)

Based on record review and interview, it was determined the facility failed to provide a current emergency preparedness testing program. Lack of a current emergency testing program covering the emergency preparedness plan and policies for the facility has the potential to hinder staff response during a disaster. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings Include:

Review of the facility emergency plan on January 8, 2018 from 11:00 AM to 4:00 PM, revealed the facility did not have a current emergency preparedness testing program. There was also no documentation that specific testing, to include an annual exercise on the emergency preparedness plan or policies had been conducted. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan to include a full scale exercise.
Reference:

42 CFR 483.73 (d) (2)

Based on record review and interview, it was determined the facility failed to provide a current emergency preparedness program with a written plan for how it will keep an onsite fuel source to power emergency power systems during an extended emergency. Lack of a current written plan, including arrangements with back-up fuel providers, could limit the facility's ability to provide continuing care and services for patients during an emergency. This deficient practice affected 2 patients, staff and visitors on the dates of the survey.

Findings Include:

Review of the facility emergency plan on January 8, 2018 from 11:00 AM to 4:00 PM, revealed the facility did not have a current plan or agreement with a provider for additional fuel for the generator in the event of an emergency. When asked, the Director of Nursing stated the facility was still working on developing a comprehensive plan.

Reference:

42 CFR 483.73 (e) (3)

Based on record review, and interview, the facility failed to develop and implement a water management plan. Failure to develop and implement a facility specific water management plan could increase risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. This deficient practice could potentially affect all patients, visitors and staff on the date of the survey. The facility is licensed for 10 beds and had a census of 2 on the day of the survey.

Findings include:

During the review of facility records on January 8, 2018, from approximately 11:00 AM to 4:00 PM, no documentation of a water management plan, to include a facility risk assessment, control measures, and testing protocols could be produced. When asked, the Administrator stated the facility was working on developing a water management plan.

Actual Standard:

42 CFR § 483.80 Infection control.

The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Additional Reference:

Centers for Medicare/Medicaid Services S&C Letter 17-30.

Based on observation, operational testing, and interview the facility failed to maintain doors that protect corridor openings. Failure to maintain corridor doors could allow smoke and dangerous gases to pass freely, preventing defend in place. This deficient practice has the potential to affect staff, and visitors on the dates of survey.

Findings include:

During the facility tour on January 9, 2018, from approximately 8:15 AM to 10:00 AM, observation and operational testing of the Dutch door to Central Supply revealed an approximately 1/2" gap between the upper and lower leaves and no astragal installed to seal the gap when fully closed. When asked, staff stated a new door was on order to replace the Dutch door.

Actual Standard:

NFPA 101
19.3.6.3.13 Dutch doors shall be permitted where they conform to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a latching device.
(2) The meeting edges of the upper and lower leaves are equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous areas, the doors comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

Based on record review, and interview, the facility failed to ensure staff were properly trained on the risks associated with the handling and use of medical gases. Failure to provide an education program which includes periodic review of safety guidelines and usage requirements for medical gases and their cylinders, could result in a life threatening or catastrophic accident. This deficient practice could potentially affect all patients using oxygen on the dates of the survey.

Findings include:

During the review of facility training records conducted on January 8, 2018, from approximately 11:00 AM to 4:00 PM, no records were available indicating that the facility maintained an ongoing continuing education program for staff which includes periodic review of safety guidelines and usage requirements for medical gases and their cylinders. When asked, the Director of Nursing stated the facility was not aware of the requirement for medical gas training.

Actual NFPA Standard:

NFPA 101
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99
11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel.
11.5.2.1.1* Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be
trained on the risks associated with their handling and use.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.