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Based on document review and interview during the survey, it was determined through on-going dialog with the Systems Director, Director of Clinical Services, Facility Manager, and Emergency Management Manager, that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(a)(3)).

Findings include:

On 7/8/2024, during record review between 3:30 pm to 5:15 pm, the facility could not provide documentation within their written EP Plan that addressed patient/client population, including patients at risk and the types of services the facility has the ability to provide in an emergency.

Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facilities Manager, and Emergency Management Manager who acknowledged the existence of these conditions.

Based on document review and interview during the survey, it was determined through on-going dialog with the System Director, Director of Clinical Services, Facilities Manager, and Emergency Management Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)).

Findings include:

On 7/8/2024, during record review between 3:30 pm and 5:15 pm, the facility failed to develop and implement EP policies and procedures, based on the risks identified in the Hazards Vulnerability Assessment (HVA).

The facility utilizes natural gas, however gas leaks was not identified as a risk on the HVA. The facility did not have a written policy or procedure for responding to a gas leak. Surveyor interviewed the Director of Clinical Services (DCS) (as the leader in charge during an emergency) regarding the response required in the event of a gas leak. When interviewed the DCS indicated she would call the maintenance staff. While surveyor provided education regarding items that need to be included in the response such as call 911, turn off the gas, and begin evacuation; the DCS responded that she did not know how to turn off the gas or where the gas shut off was located.

Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facility Manager, and Emergency Management Director who acknowledged the existence of these conditions.

Based on document review and interview during the survey, it was determined through on-going dialog with the Systems Director, Director of Clinical Services, Facility Manager and Emergency Management Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(1)).

Findings include:

On 7/8/2024, during record review between 3:30 pm and 5:15 pm, the facility failed to provide evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (i) defined policies and/or protocols for medical, and pharmaceutical supplies of staff.

Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facility Manager and Emergency Management Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Systems Director, Director of Clinical Services, Facility Manager and Emergency Management Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(2)).

Findings include:

On 7/8/20224, during record review between 3:30 pm and 5:15 pm, the facility failed to provide a defined system to track the location of on-duty staff during an emergency.

Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facility Manager and Emergency Management Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Systems Director, Facility Manager and Emergency Management Manager that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for universe all extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.12, NFPA 418 and NFPA 10).

Findings include:

On 7/9/2024, at 10:39, there was no documentation for monthly inspections for the portable fire extinguisher for the heliport at the hospital. The heliport is operated by Life Flight under contracted agreement with the facility on the hospital grounds.

Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facilities Manager and Emergency Management Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Systems Director, Facilities Manager and Emergency Management Manager that the facility failed to maintain/construct at least a 1-hour fire resistance rated smoke barrier for 2 of 3 sampled smoke compartments of the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3, 19.3.7.4, 19.3.7.5 8.3, and 8.5).

Findings include:

1. On 7/9/2024, at 10:35 am, there were multiple openings/penetrations in the ceiling of the Riser Room that was greater than 2 inches that would allow for the spread of smoke or fire to other areas of the facility.

2. On 7/9/2024, at 11:09 am, there were multiple openings/penetrations in the ceiling of Electrical Room 301080 near 100 clinic that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility.

3. On 7/9/2024, at 11:10 am, there were multiple openings/penetrations in the ceiling of 200 Electrical Room 301018 that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility.

4. On 7/9/2024, at 11:24 am, there were multiple openings/penetrations in the ceiling of the IDF Room that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility.

5. On 7/9/2024, at 11:25 am, there were multiple openings/penetrations in the ceiling of the UPS Room that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility.

Surveyor was accompanied at exit by the Facility Administrator, Systems Director, Director of Clinical Services, Facilities Manager and Emergency Management Manager who acknowledged the existence of these conditions