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Based on record review and interview, the facility failed to develop an emergency plan in accordance with regulatory requirements. This was evidenced by the failure to include strategies for addressing hazards identified in the risk assessment. This affected 10 of 10 patients and 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 record review with staff on 3/14/18, the Emergency Management Procedures were reviewed.

1. At 11:11 a.m., the emergency plan failed to address hazards identified by the risk assessment. Temperature extremes was rated as having a high probability of occurrence but it was not addressed in the emergency plan. Seasonal influenza was rated as having a moderate probability of occurrence but was not addressed in the emergency plan. Mass casualty incident was rated as having a moderate probability of occurrence but was not addressed in the emergency plan.
During a concurrent interview, Maintenance Staff 1 stated that the risk assessment provided was from 11/29/17 and the emergency plan was last reviewed on 8/30/17. The emergency plan was last reviewed before the risk assessment was conducted.

Based on record review and interview, the facility failed to establish all required emergency preparedness policies and procedures (P&Ps). This was evidenced by an outdated P&P for subsistence water provisions, by no P&P to maintain temperatures to protect patient health and safety or the safe and sanitary storage of subsistence provisions, by no P&P for a system of medical documentation that preserves confidentiality and maintains the availability of records, and by no P&P for the role of the facility under a 1135 waiver during a national disaster. This affected 10 of 10 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 record review with staff on 3/14/18, the P&Ps were requested.

1. At 11:55 a.m., the P&P provided for emergency water provisions indicated that the facility would keep two tank loads onsite.
During a concurrent interview, facility leadership were asked to elaborate on the meaning of two tank loads. Adm1 and Maintenance Staff 1 stated they were unsure what that meant. Maintenance STaff 1 stated that the P&P was outdated.

2. At 12:05 p.m., there was no P&P provided regarding alternate sources of energy to maintain the temperatures for the health and safety of patients or to maintain the safe and sanitary storage of subsistence provisions.

3. At 1:50 p.m., there was a P&P for length of time paper-form medical records are retained in the facility. There was no P&P addressing the security of the electronic medical records system and a contingency plan for the system's failure.
During a concurrent interview, Adm1 and Maintenance Staff 1 confirmed that there was no policy addressing the electronic medical system.

4. At 1:55 p.m., there was no P&P to address the role of the facility under a 1135 waiver during a nationally declared disaster.

Based on record review and interview, the facility failed to provide all the required elements of a communication plan. This was evidenced by no method to release patient information in the event of a disaster and by no method to share information with the authority having jurisdiction. 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 record review with staff on 3/14/18, the communication plan was provided.

1. At 2:10 p.m., there was no method of sharing general patient information in the event of an emergency.

2. At 2:13 p.m., there was no method of sharing occupancy information, needs, and ability to help to the authority having jurisdiction.
During a concurrent interview, Maintenance Staff 1 stated that the facility was signed up with the reporting system of the Inland Counties Emergency Medical Agency (ICEMA) and showed a copy of a situation report sent to the county agency during an actual event back in September. He confirmed that this reporting method was not outlined in the communication plan.

Based on observation, record review, and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by the use of portable dehumidifiers in the ORs. This was also evidenced by a relative humidity range in the facility's policy that was not compatible with electro-medical and sterile equipment used in the ORs. This affected patients undergoing procedures in two of two ORs. This could result in the increased risk of a hazardous condition and a fire in the oxygen-rich environment of the ORs.

NFPA 101, Life Safety Code, 2012 Edition.
4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 99, Health Care Facilities Code, 2012 Edition.
9.3.1.1 Heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities, shall be provided in accordance with ASHRAE 170.

On 4/19/13, the Centers for Medicare & Medicaid Services (CMS) released memorandum S&C: 13-25-LSC & ASC titled "Relative Humidity (RH): Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements; Discussion of Ambulatory Surgical Center (ASC) Operating Room Requirements." The memorandum stated: "The 2012 edition of NFPA 99 has adopted the 2008 edition of the American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities. Addendum D of the ASHRAE standard requires RH in anesthetizing locations to be maintained between 20 - 60 percent. In addition, this ASHRAE standard has been incorporated into the Facility Guidelines Institute (FGI) 2010 Guidelines for Design and Construction of Health Care Facilities, and has been approved by the American Society for Healthcare Engineering of the American Hospital Association and the American National Standards Institute." The memorandum also stated: "Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20 percent. When outdoor humidity and internal moisture are not sufficient to achieve the minimum humidity level, then humidification must be provided by means of the hospital's or CAH's ventilation systems. In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range."

Centers for Medicare & Medicaid Services (CMS) memorandum "S&C: 15-27-Hospital, CAH & ASC Potential Adverse Impact of Lower Relative Humidity (RH) in Operating Rooms (ORs)" stated "it has come to light that an RH level <30% is not compatible with the instructions for use (IFUs) for some sterile supplies and electro-medical equipment used in operating rooms" and "CMS expects hospitals, CAHs and ASCs to follow the current IFUs for supplies and equipment used in their ORs."

Findings:

During a facility tour with Maintenance Staff 1 from 3/13/18 to 3/14/18, the anesthetizing locations were observed and the relative humidity records were provided.

1. At 1:11 p.m., on 3/13/18, there was a portable dehumidifier in OR 1 and it was in use.
During a concurrent interview, Maintenance Staff 1 stated that the facility's HVAC system had a humidification system but not a dehumidification system. He said he conducts annual visual and electrical wiring inspections on the portable dehumidifiers annually and the housekeeping staff clean the filters and wipe the equipment down.

2. At 1:20 p.m., on 3/13/18, there was a portable dehumidifier in OR 2. The portable dehumidifer had a trouble light indicating that the water tank was full.

At 8:45 a.m., on 3/14/18, the facility's policy regarding the ambient conditions in the ORs stated that the dehumidifier units would be used to maintain the desired humidity range.

The manufacturer's specifications of the dehumidifiers did not indicate that they were to be used in an oxygen-rich sterile environment.

AORN Recommended Practices for Environment of Care (2017) states "free-standing fans, humidifiers, or dehumidifiers should not be used in the operating room or sterile processing areas."

3. At 9:25 a.m., on 3/14/18, the facility's policy regarding the ambient conditions in the ORs stated that relative humidity was to be maintained between 20% to 60%. Maintenance Staff 1 provided manuals of operation for four pieces of equipment used in the ORs. Manuals for two of four equipment, including the light source for the endoscope and the tourniquet system, called for a minimum of 30% operating relative humidity.
During a concurrent interview, Maintenance Staff 1 confirmed the finding and stated that he would conduct an inventory of which equipment require a minimum of 30% operating relative humidity.

At 9:30 a.m., on 3/14/18, the temperature and humidity logs showed that the humidity was above 20% but below 30% in both ORs during 17 days of February 2018, 13 days in January 2018, and 20 days in December 2017.

Based on observation, record review, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by grease-laden deposits in the kitchen hood, by the failure to establish a hood inspection frequency in accordance with NFPA 96, and by an external load on the fire extinguishing system piping. This affected one of five smoke compartments and this could result in the increased risk of a grease fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition.
10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

11.4 Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4.

Table 11.4 Schedule of Inspection for Grease Buildup
Type or Volume of Cooking: Inspection Frequency
Systems serving high-volume cooking operations, such as 24-hour cooking, charbroiling, or wok cooking: Quarterly.

Systems serving moderate-volume cooking operations: Semiannually.

Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers: Annually

11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction.

11.6.2 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge.

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 edition.
7.2 Owner's Inspection.
7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer ' s listed installation and maintenance manual or the owner's manual.

7.2.2 At a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable
range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

7.2.3 If any deficiencies are found, appropriate corrective action shall be taken immediately.

Findings:

During a facility tour with Maintenance Staff 1 from 3/13/18 to 3/14/18, the kitchen was observed and maintenance records were reviewed.

1. At 9:45 a.m., on 3/13/18, there was a hose hanging on the Ansul system pipe above the cooking equipment.
During a concurrent interview, Cook 1 was asked what the hose was for. She stated she thought it was part of the grease fire extinguishing system. Maintenance Staff 1 stated that it was a water hose and should not be used for a grease fire and should not be hanging on the Ansul pipes.

2. At 9:47 a.m., on 3/13/18, Maintenance Staff 1 removed a filter from the kitchen hood. The filter was dripping with grease and there were thick grease-laden deposits in the hood.

At 10:10 a.m., on 3/13/18, logs provided by Cook 1 indicated that the kitchen hood filters were cleaned by staff once a month.
During a concurrent interview, Maintenance Staff 1 stated that the filters should have been on a weekly cleaning schedule.

At 3:00 p.m., on 3/13/18, a vendor report from 9/30/15 stated "system filters need to be cleaned weekly."

3. At 2:59 p.m., on 3/13/18, maintenance records provided showed that the kitchen hood was last professionally cleaned on 9/14/17. During a concurrent interview, Maintenance Staff 1 stated that the facility stated that, based on their cooking volume, they have a vendor clean the hood on an annual basis.

At 3:00 p.m., on 3/13/18, records provided showed that the hood was cleaned by a vendor on 9/14/17 and 9/30/15. There were no records of cleaning the hood in 2016 and an annual schedule for cleaning the hood could not be established.
During a concurrent interview, Maintenance Staff 1 confirmed the finding and stated that the cleaning may have been skipped in 2016.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler heads with missing escutcheon fittings, by the failure to provide a complete spare sprinkler supply, and by no records of inspecting the fire department connections on a quarterly basis. This affected five of five smoke compartments and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

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.
4.3.1 Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

4.7 Maintenance. Maintenance shall be performed to keep the system equipment operable or to make repairs.

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)

5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:
(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5
(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6

5.4.1.4 A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.

5.4.1.4.1 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property.

13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.

Findings:

During a facility tour with Maintenance Staff 1 from 3/13/18 to 3/14/18, the automatic sprinkler system was observed and maintenance records were reviewed.

1. At 9:17 a.m., on 3/13/18, the sprinkler head in the dietary storage closet was completely covered in paper.
During a concurrent interview, Maintenance Staff 1 stated that the painters forgot to remove the paper and that he could not recall how long ago the room was painted.

2. At 9:35 a.m., on 3/13/18, the spare sprinkler head box in the sprinkler riser room was observed. The main electrical room and the riser room were protected by upright sprinkler heads. There were no upright sprinkler heads in the spare sprinkler box.
During a concurrent interview, Maintenance Staff 1 confirmed the finding and stated that the entire spare sprinkler inventory was in that box.

3. At 9:42 a.m., on 3/13/18, the sprinkler head in the Computer Lab was missing its escutcheon skirt and a penetration in the ceiling around the sprinkler pipe was exposed.

4. At 9:59 a.m., on 3/13/18, the sprinkler head in the corridor outside the laundry department was missing its escutcheon skirt and a penetration in the ceiling around the sprinkler pipe was exposed.

5. At 3:45 p.m., on 3/13/18, there were no records of inspecting the fire department connections on a quarterly basis.
During a concurrent interview, Maintenance Staff 1 stated that he inspected the fire department connections quarterly but did not put it in writing.

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls. This was evidenced by unsealed conduits in the smoke barrier walls. This affected four of five smoke compartments and could result in the faster spread of smoke and fire.

NFPA 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)(c).
(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.

8.3.5.1 Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust 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 fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly.

8.3.5.1.3 Firestop systems and devices shall have a minimum 1-hour F rating, but not less than the required fire resistance rating of the fire barrier penetrated.

Findings:

During a facility tour with Maintenance Staff 1 from 3/13/18 to 3/14/18, the smoke barrier walls were observed.

1. At 10:43 a.m., on 3/13/18, there was an approximately 1 1/2 inch unsealed conduit in the smoke barrier wall near the surgery staff changing room. There were white cables going through the conduit.

2. At 10:50 a.m., on 3/13/18, there was an approximately 1 1/2 inch unsealed conduit in the smoke barrier wall across the cafeteria. There were white cables going through the conduit.
During a concurrent interview, Maintenance Staff 1 confirmed the finding and stated that the conduits with the white cables were for the new security camera system.

3. At 11:20 a.m., on 3/13/18, there was an approximately 1 1/2 inch unsealed conduit in the smoke barrier wall near Room 101. There were white cables going through the conduit.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift. This was evidenced by the failure to conduct fire drills in accordance with the shift schedules of all facility personnel, by no records of a morning shift fire drill in the second quarter (April to June) of 2017, and by no records of night shift drills in the third quarter (July to September) of 2017. This affected 10 of 10 patients and could result in a delay in staff response, in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.7.1.4 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Findings:

During record review with Maintenance Staff 1 from 3/13/18 to 3/14/18, the fire drill records were provided.

1. At 2:30 p.m., on 3/13/18, records provided showed that only one fire drill was conducted during the second quarter of 2017. That fire drill was conducted on 5/31/17 at 7:35 p.m. The records also showed that only one fire drill was conducted during the third quarter of 2017. That fire drill was conducted on 7/28/17 at 1:34 p.m.
During a concurrent interview, Maintenance Staff 1 stated he held fire drills in accordance with the nursing staff's 12-hour-shifts and he made an effort to hold them at times that would include staff that work 8-hour-shifts. He stated that based on the 12-hour-shifts, there was a missing AM (morning) shift fire drill during the second quarter and missing NOC (night) shift drill during the third quarter.

Based on observation and interview, the facility failed to ensure that portable space heaters used in employee areas have heating elements in accordance with the Code. This was evidenced by the failure to provide information on the temperature of the heating elements of one portable space heater. This affected one of five smoke compartments and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.7.8 Portable Space-Heating Devices. Portable spaceheating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).
Findings:

During a facility tour with Maintenance Staff 1 from 3/13/18 to 3/14/18, the facility was observed for portable space heaters.

1. At 10:11 a.m., on 3/13/18, there was a portable space heater in the laboratory reception room. The space heater was plugged in but not in use. There was no information provided by the maximum temperature of the heating elements.
During a concurent interview, Maintenance Staff 1 was asked what the facility's policy on the use of portable space heaters. He stated that they are prohibited in patient care areas and the ones in use in staff offices were inspected twice a year.

During an interview at 1:03 p.m., on 3/13/18, Maintenance Staff 1 stated he did not have information about the temperature of the heating elements of the space heaters used in the facility.

Based on observation and interview, the facility failed to maintain their electrical wiring. This was evidenced by electrical boxes and outlets with missing or broken covers, and by a trouble signal exhibited for one line isolation monitors (LIM). This affected three of five smoke compartments and one of two ORs. This could result in the increased risk of electrical fire and electrical shock.

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

9.1.2 Electrical 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.
314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B).

NFPA 99, Health Care Facilities Code, 2012 Edition.
6.3.2.6.3.1 In addition to the usual control and protective devices, each isolated power system shall be provided with an approved, continually operating line isolation monitor that indicates possible leakage or fault currents from either isolated conductor to ground.

6.3.2.6.3.2 The monitor shall be designed such that a green signal lamp, conspicuously visible in the area where the line isolation monitor is utilized, remains lighted when the system is adequately isolated from ground; and an adjacent red signal lamp and an audible warning signal (remote if desired) shall be energized when the total hazard current (consisting of possible resistive
and capacitive leakage currents) from either isolated conductor to ground reaches a threshold value of 5.0 mA under normal line voltage conditions. The line isolation monitor shall not alarm for a fault hazard current of less than 3.7 mA.

6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.

6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2.

Findings:

During a facility tour with Maintenance Staff 1 from 3/13/18 to 3/14/18, the electrical wiring was observed.

1. At 9:15 a.m., on 3/13/18, the duplex outlet in the patio outside the Emergency Department had a broken cover and the interior of the electrical box was observed.

2. At 9:40 a.m., on 3/13/18, there was a 4 by 4 junction box in the ceiling of the boiler room that was mising a cover. The wiring in the junction box was exposed and hanging down.

3. At 11:12 a.m., on 3/13/18,the duplex outlet outside the shower room in the former Rehabilitation Wing was missing its cover and the plugs were covered with blue electrical tape.

4. At 1:15 p.m., on 3/13/18, the line isolation monitor (LIM) in OR 1 exhibited an "error" message and had a "hazard" trouble light on.
During a concurrent interview, Maintenance Staff 1 stated he was aware of the error was trying to schedule someone to come out to do the repair. He said the vendor told him over the phone that the safety of the system was not compromised.

Based on record review, the facility failed to maintain their emergency generator. This was evidenced by no records of monthly conductance testing of the generator batteries and by no records of an annual fuel quality test. This affected 10 of 10 patients and could result in the increased risk of generator failure.

NFPA 99, Health Care Facilities Code, 2012 Edition.
6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

6.4.4.2 Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition.
1.1.2 This standard covers installation, maintenance, operation, and testing requirements as they pertain to the performance of the emergency power supply system (EPSS).

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards

Findings:

During record review with Maintenance Staff 1 from 3/13/18 to 3/14/18, the generator maintenance records were provided. The facility was equipped with a 350kW diesel-fuel generator.

1. At 8:25 a.m., on 3/14/18, records provided showed that a conductance test was performed quarterly on the generator batteries. The conductance tests were performed on 3/31/17, 6/25/17, 9/28/17, and 12/27/17. There were no records of monthly conductance tests.

2. At 8:30 a.m., on 3/14/18, the facility's generator had a a day tank and an underground fuel tank. there were no records of an annual fuel quality test.

Based on record review and interview, the facility failed to ensure that fire loss prevention procedures were established for the Operating Rooms (ORs) and that continuing education of those procedures were conducted. This was evidenced by no records of such procedures or training. This affected patients and staff during procedures in two of two ORs and could result in the increased risk of a fire.

NFPA 99, Health Care Facilities Code, 2012 Edition.
15.13 Fire Loss Prevention in Operating Rooms.
15.13.1 Hazard Assessment.
15.13.1.1 An evaluation shall be made of hazards that could be encountered during surgical procedures.

15.13.1.2 The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment.

15.13.1.3 Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.

15.13.3.9 Emergency Procedures.
15.13.3.9.1 Procedures for operating room/surgical suite emergencies shall be developed.

15.13.3.9.2 Procedures shall include alarm actuation, evacuation, and equipment shutdown procedures and provisions
for control of emergencies that could occur in the operating room, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.

15.13.3.9.4 Emergency procedures shall be established for extinguishing drapery, clothing, or equipment fires.

15.13.3.10 Orientation and Training.
15.13.3.10.1 New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use.

15.13.3.10.2 Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.

Findings:

During record review with Maintenance Staff 1 from 3/13/18 to 3/14/18, records regarding fire loss prevention measures in the ORs were requested.

1. At 3:15 p.m., on 9/14/18, Maintenance Staff 1 provided a policy titled "Fire in Surgical Services." The policy outlined response procedures for a "Code Red" in the OR.
During a concurrent interview, Maintenance Staff 1 stated that this was the only documentation available regarding fire in the ORs. He stated that he occasionally goes through fire drill procedures with OR staff but does not have records of an OR fire drill.
The facility failed to provide evidence that an evaluation of hazards in the ORs was conducted, that fire loss prevention procedures were established, or training regarding those hazards and measures were conducted.