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Based on document review and interview, the facility failed to maintain the emergency preparedness (EP) plan. This was evidenced by failing to review and update the EP plan annually, and by failure to provide a written emergency plan for program patient population. This affected five of five smoke compartments. This could result in a delay in preparedness and proper response, in the event of an emergency.

§485.625: The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least annually. The plan must do all of the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

(2) Include strategies for addressing emergency events identified by the risk assessment.

(3) Address patient/client population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

(4) Include 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 or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

Findings:

During document review and interview with the EPC on 4/9/19, the EP plan was reviewed.

1. At 8:41 a.m., the facility failed to maintain and update the EP plan at least annually. The date of when the disaster plan was last reviewed was on January 2018. The finding was confirmed by the EPC.

2. At 9:38 a.m., the facility failed to provide a written emergency plan that addressed patient population, the type of services, that the facility can provide in an emergency; and continuity of operations. The finding was confirmed by the EPC.

Based on document review and interview, the facility failed to maintain the emergency preparedness (EP) plan. This was evidenced no Policy and Procedure (P&P) for a system of medical documentation that preserves confidentiality and maintains the availability of records. This affected six of six patients and could result in a delay adequate response and preparation, in the event of an emergency.

§485.625: The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

(2) A system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the facility must document the specific name and location of the receiving facility or other location.

(3) Safe evacuation from the facility, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

(4) A means to shelter in place for patients, staff, and volunteers who remain in the facility.

(5) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

(6) The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

(7) The development of arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

(8) The role of the facility 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.

Findings:

During document review with the EPC on 4/9/19, the P&Ps were requested.

At 10:59 a.m., there was no written P&P for medical documents that preserves/protects patient information and maintain availability. When interviewed the EPC stated that they currently working on their P&P.

Based on document review and interview, the facility failed to develop and maintain an emergency preparedness (EP) communication plan. This was evidenced by no methods of sharing information to maintain the continuity of care. This affected five of five smoke compartments. This could result in a delay in communicating vital information during an emergency.

§485.625: The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

(4) A method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care.
(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii).
(6) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).
(7) A means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Findings:

During document review with the EPC on 4/9/19, the communication plan was reviewed.

At 10:03 a.m., the facility failed to provide a method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care. When interviewed, the EPC stated that they are currently working on developing this part of information on their EP communication plan.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the ceiling. This affected one of five smoke compartments. This could result in the expedited spread of smoke or fire to other areas of the facility.

Findings:

During a tour of the facility with the POM on 4/9/19, the ceiling was observed.

At 2 p.m., there were three ceiling penetrations observed in the Server Room. The penetrations measured approximately 1/2 inch to 1 1/2 inches. When interviewed, the POM confirmed the findings.

Based on observation and interview, the facility failed to maintain the self-closing doors. This was evidenced by a door that failed to close when tested. This affected one of five smoke compartments and could result in the passage of smoke in the event of a fire.

Findings:

During a tour of the facility with the POM on 4/9/19, the self-closing doors were observed and tested.

At 1:45 p.m., the exit door near Room 11 was equipped with a self-closing device. The door was opened to the fullest extent and released. The self-closing door failed to fully close and latch. The door was tested four times and failed. When interviewed, the POM stated that the bottom of the door needed cleaning.

Based on document review and interview, the facility failed to maintain the anesthetizing locations. This was evidenced by the failure to maintain the humidity level according to their policy for temperature and humidity in the procedure room. This affected one of five smoke compartments, and could result in the ignition of fire in the operating rooms.

Findings:

During document review and interview with the POM on 4/8/19, the procedure room humidity level logs were reviewed.

At 3:02 p.m., the humidity log for one procedure room was reviewed. The readings of the humidity level for the procedure room were below 35 percent. The policy for humidity level indicated between 35-60% range requirement. The reading of the humidity level for the past twelve months were reviewed and the humidity level fell below 35%:

1/3/19 - 17%
2/7/19 - 25.5 %
4/12/18 - 30%; 4/19/18 - 33%
8/2/18 - 31%; 8/8/18 - 33.6%
10/25/18 - 29%
11/8/18 - 31%; 11/15/18 - 31%
12/13/18 - 29%; 12/27/18 - 28.4%

When interviewed, the POM confirmed the findings.

Based on observation and interview, the facility failed to maintain their smoke detectors. This was evidenced by failure to conduct weekly testing for the maintenance of a single station smoke detector in accordance with manufacturer's specifications. This affected one of five smoke compartments and could result in a delay in residents and staff notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
9.6.2.10.1.1 Where required by another section of this Code, single-station and multiple-station smoke alarms shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code, unless otherwise provided in 9.6.2.10.1.2, 9.6.2.10.1.3, or
9.6.2.10.1.4.

NFPA 72, National Fire Alarm Code, 2010 Edition
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.1.2 The inspection, testing, and maintenance of single and multiple-station smoke and heat alarms and household fire alarm systems shall comply with the requirements of this chapter.
14.1.3 Procedures that are required by other parties and that exceed the requirements of this chapter shall be permitted.
14.1.4 The requirements of this chapter shall apply to both new and existing systems.

Findings:

During a tour of the facility and interview with the POM on 4/9/19, the single station smoke alarm was observed.

At 1:49 p.m., a single-station smoke alarm with battery back-up was observed in the Social Dining Room. The preventive maintenance for the single station smoke alarm with battery back-up was requested. When interviewed, the POM stated there was no preventive maintenance for the battery back-up smoke detector for it was no longer in use. He stated that he was not aware that it was still in the Social Dining Room.

Based on interview and document review, the facility failed to maintain their automatic fire sprinkler systems. This was evidenced by the failure to maintain the sprinkler heads. This affected three of five smoke compartments. This could result in a delayed notification of a malfunctioning automatic fire sprinkler system.

NFPA 101, Life Safety Code, 2012 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.

Findings:

During a tour of the facility and interview with the POM , the automatic sprinkler system was observed.

1. On 4/9/19, at 1:07 p.m., the sprinkler head in the Janitor Room penetrated through the ceiling. When interviewed, the POM confirmed the finding and stated that the bracing of the sprinkler pipe needed adjusting.

2. On 4/9/19, at 1:38 p.m., there was foreign material on two of two sprinkler heads, in Room 7. The findings were confirmed by the POM.

3. On 4/9/19, at 2:13 p.m., there was foreign material on the sprinkler head in the wash area located in the Kitchen. When interviewed, the POM confirmed the finding and stated that he will call their sprinkler vendor.

4. On 4/10/19, at 8:28 a.m., the sprinkler head in the Biohazard Room penetrated through the ceiling. When interviewed, the POM confirmed the finding and stated that the bracing of the sprinkler pipe needed adjusting.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by fire extinguishers that were obstructed from immediate access, and by an unsecured fire extinguisher. This affected two of five smoke compartments. This could result in the device to malfunction in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses
6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.
6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.

7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators

Finding:

During a tour of the facility and interview with the POM, the facility's fire extinguishers were observed.

1. On 4/9/19, at 1:20 p.m., the fire extinguisher near Emergency Room 3 was obstructed by a metal supply cart and a soiled linen barrel placed in front of the portable fire extinguisher. When interviewed, the POM confirmed the finding.

2. On 4/9/19, at 2:14 p.m., the Class K fire extinguisher located in the Kitchen was obstructed by a metal cart. When interviewed, the POM confirmed and stated that the metal cart will be relocated.

3. On 4/10/19, at 8:50 a.m., the fire extinguisher located in the basement was placed freestanding and unsecured on top of a table. When interviewed, the POM confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by doors that failed to positive latch. This affected four of five smoke compartments and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a tour of the facility and interview with the POM, the corridor doors were observed.

1. On 4/9/19, at 1:17 p.m., the door to the Soiled Utility Room located in the Emergency Room failed to latch when manually tested. When interviewed, the POM stated that a work order had already been submitted for the replacement of the door handler.

2. On 4/9/19, at 1:27 p.m., the door to the Shower/Locker Room across from the Nurse Station was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested two times and failed. The finding was confirmed by the POM.

3. On 4/9/19, at 2:02 p.m., the door to the Restroom near the Soiled Utility Room was equipped with a self-closing device that failed to latch when fully opened and released. When interviewed, the POM stated that the latch was broken.

4. On 4/9/19, at 2:03 p.m., the door to the Environmental Services Soiled Utility Room was equipped with a self-closing device that failed to latch when fully opened and released. When interviewed, the POM stated that the self-closure device needed adjusting.

5. On 4/10/19, at 8:28 a.m., the door to the Biohazard Room was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested three times and failed. When interviewed, the POM confirmed the finding.

Based on observation and interview, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by an unsealed penetration in the smoke barrier walls. This could result in the spread of smoke and fire and increase the risk of injury to patients and staff in the event of a fire. This affected one of five smoke compartments.

NAPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac).
(B) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

Findings:

During a tour of the facility with POM on 4/10/19, the smoke barrier walls were observed.

At 8:37 a.m., there was an approximately 3/4 inch unsealed penetration around two wires in the smoke barrier wall. The smoke barrier wall was located near the Utility Room and Room 8. When interviewed, POM confirmed the finding.

Based on document review and interview, the facility failed to maintain their heating, ventilating, and air-conditioning (HVAC) system. This was evidenced by the failure to repair fire dampers that failed during the testing and maintenance service. This affected five of five smoke compartments and could result in the faster spread of smoke and fire through the HVAC system.

NFPA 101, Life Safety Code, 2012 Edition
21.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be in accordance with the manufacturer's specifications, unless otherwise modified by 21.5.2.2.

9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition
5.4.7.1 Fire dampers, including their sleeves; smoke dampers; and ceiling dampers shall be installed in accordance with the conditions of their listings and the manufacturer's installation instructions and the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives.

NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition
19.4.1 Each damper shall be tested and inspected 1 year after installation.

19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

19.4.2 All tests shall be completed in a safe manner by personnel wearing personal protective equipment.

19.4.3 Full unobstructed access to the fire or combination fire/ smoke damper shall be verified and corrected as required.

19.4.4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped.

19.4.5 The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.

19.4.6 The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations.

19.4.7 The damper shall not be blocked from closure in any way.

19.4.8 The fusible link shall be reinstalled after testing is complete.

19.4.8.1 If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating.

19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/ smoke damper, date of inspection, name of inspector, and deficiencies discovered.

19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected.

19.4.10 All documentation shall be maintained and made available for review by the AHJ.


Findings:

During document review and interview with the POM on 4/8/19, the fire damper maintenance documents were requested.

At 2:50 p.m., the document provided for the fire damper inspection dated 7/6/16 and 7/7/16 was reviewed. The fire damper report indicated that two dampers failed the inspection. The failed items are: 1FD-002B-Bent Tracks and 1FSD-081-Inoperable Actuator. The repair documents were requested. The POM failed to provide the repair documents during the survey.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by the failure to prohibit the use of power strips as substitutes for permanent fixed wiring. This could result in an increased risk of an electrical fire and or electrical shock. This affected four of five smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.2 Electric Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

Findings:

During a tour of the facility with the POM on 4/9/19, the electrical wiring and equipment was observed.

1. At 1:04 p.m., an air conditioner was plugged into a power strip, in the Clean Linen/Housekeeping Room. The finding was confirmed by the POM.

2. At 1:22 p.m., a coffee maker and a microwave were plugged into a power strip, in the Nurse Break Room. The findings were confirmed by the POM.

3. At 1:23 p.m., a water dispenser was plugged into a power strip, in the Doctors' Room.

4. At 1:40 p.m., an IV Pump machine was plugged into a power strip, in the Clean Utility Room. The finding was confirmed by the POM.