HospitalInspections.org

Based on observation, document review and staff interview it was revealed the facility failed to develop and maintain a comprehensive emergency preparedness program that complies with all applicable Federal, State and local emergency preparedness requirements. The facility's census was zero (0).

Findings include:

1. Document review on 12/01/20 at approximately 10:30 a.m. revealed the facility failed to comply with the following emergency preparedness elements:

(a) The emergency plan was not based on or included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

(b) The emergency plan did not include policy or procedure for volunteers.

(c) The emergency plan did not include arrangements with other facilities.

(d) The emergency plan did not include roles under a waiver declared by the Secretary.

(e) The emergency plan did not include emergency officials contact information.

2. An interview with the Maintenance Manager on 12/01/20 at approximately 4:00 p.m. verified these findings.

3. These findings were verified with the Administrator at the time of exit on 12/01/20 at approximately 4:30 p.m.

Based on observation, document review and staff interview it was revealed the facility failed to meet the provisions applicable to Critical Access Hospitals (CAH) of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was zero (0).

Findings include:

1. Document review on 12/01/20 at approximately 11:00 a.m. revealed the facility failed to ensure that the fire doors assemblies were inspected and tested annually.

2. An interview with the Maintenance Manager on 12/01/20 at approximately 2:00 p.m. verified these findings.

3. These findings were verified with the Administrator at the time of exit on 12/01/20 at approximately 4:30 p.m.