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Based on record review and interview the facility failed to ensure addressing their patient population within the facility emergency preparedness plan as required at CFR 482.15(a).

Findings:

Record review showed the facility emergency preparedness plan did not address or include the facility's patient/client population. The facility emergency preparedness plan did not contain strategies the facility would or will put in place to address the needs of at-risk or vulnerable patient populations it serves, or the services the facility would be able to provide during an emergency event.

On 12/29/20 at 2:30 pm the surveyor asked staff A to see where in the facility emergency preparedness plan the facility addressed the patient/client population they serve. Staff A stated they could not find where paitent population was addressed but will add it.

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 12/29/20 at 11:38am the surveyor asked staff A to show them where in the communication the information on occupancy/needs was to comply with E34 tag. Staff A stated it was not included but will be easily added.

Based on observation and interview the facility failed to ensure two hour separation from the business occupancies as required in NFPA 101, 2012 Edition Chapter 8.

Findings:

On 12/29/20 at 2:13pm the surveyor observed two areas on the third floor which housed an orthopedic clinic and eye clinic.

On 12/29/20 at 2:13pm the surveyor asked staff A if the two clinics were departments of the facility and he stated no that they lease the area from the hospital. The surveyor advised the requirement with non-contiguous occupancies is there must be two hour fire wall separation. Staff A stated they will address that and take care of it.

Based on record review and interview, the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required in NFPA 101, 2012 Edition, Chapter 19.7.1.4 through 19.7.1.7.

Findings:

Record review of the facility's fire drill documentation showed each fire drill did not include verification of a transmission of a fire alarm signal.

On 12/29/20 at 10:32 am staff A was asked to show the surveyor where they document how they verify the transmission of a fire alarm signal. Staff A stated they did not document it on the fire drill report forms but will add it from this point on.

Based on record review and interview the facility failed to ensure operating room staff completed specific training on features of fire protection and fire loss prevention in operating rooms as required.

Findings:

Record review showed no fire drills for operating room staff for emergency procedures which included the following: equipment fires, alarm activation, evacuation, equipment shutdown, and control operations in addition to continuing education. Operating room emergency procedures training did not include surgeons/doctors as required in NFPA 99, 15.13.

On 12/30/20 at 10:04am the surveyor asked staff A if the operating room staff performed actual practical fire drills in the operating room which included each of the items outlined in K933. Staff A stated the operating room staff do fire drills but the doctors do not participate. The surveyor stated they will have to include each of the outlined items in K933 to include doctors.