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Base on a complaint investigation PR00000666 and Emergency Preparedness (EP) survey and review of the emergency preparedness plan, perform on 09/27/22 on 9:00 AM, it was determined that the facility failed to develop and maintain policies and procedures related with 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.

Findings include:

The facility's emergency preparedness did not include policies and procedures which outline the facility's role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites.

Base on a complaint investigation PR00000666, Emergency Preparedness Survey, Policy and Procedure Review, and interview with the Enginer employee #3 conducted on September 27, 2022 from 8:40 AM till 2:20 PM, it was determined that the facility failed to ensure that the Emergency generator backup dieseal was sign accordance to the requirements found in the Life Safety Code (NFPA 101 in compliance with NFPA 30).


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Findings include:

During the tour to the facility's Diesel backup performed on 09/27/2022 at 11:00 AM with the engineer employee #3 and the Associate administrator employee #1, it was observed that the diesel tank backup did not have the proper regulatory identification sing as requirement of NFPA 101 Life Safety Code standard section 8.7.3, reference of NFPA 30 for Flammable and Combustible Liquids Code for class II type combustibles.