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Based on document review and staff interview, the facility failed to review and update emergency preparedness policies and procedures at least every two years. The findings were:

Review of the Emergency Preparedness Plan on 06/09/2021 starting at 1:00 PM revealed that the plan was last updated in 2016.

Interview with the facilities planning & plant operations supervisor, as well as the facility's emergency coordinator, at the time of document review acknowledged the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.
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Based on document review and staff interview, the facility failed to provide a system to track the location of on-duty staff and sheltered patients during an emergency. The findings were:

Review of the Emergency Preparedness Plan on 06/09/2021 starting at 1:00 PM revealed that the facility's plan included language requiring staff to track the location of relocated patient and on-duty staff, but that no details were provided as to the methods or technology to be used. Plan language was overly vague, and did not provide adequate instructions for use during an emergency.

Interview with the facilities planning & plant operations supervisor, as well as the facility's emergency coordinator, at the time of document review acknowledged the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.
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Based on document review and staff interview, the facility failed to provide policies and procedures for medical documentation. The findings were:

Review of the Emergency Preparedness Plan on 06/09/2021 starting at 1:00 PM revealed that the facility's plan did not include a policy or procedure to provide a system of medical documentation to preserve patient information, protect patient confidentiality, and secure records.

Interview with the facilities planning & plant operations supervisor, as well as the facility's emergency coordinator, at the time of document review acknowledged the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.
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Based on document review and staff interview, the facility failed to provide policies and procedures for volunteers. The findings were:

Review of the Emergency Preparedness Plan on 06/09/2021 starting at 1:00 PM revealed that the facility did not provide a policy or procedure for the use of volunteers, or other staffing strategies, including integration of State and Federally designated health care professionals to address a surge during an emergency.

Interview with the facilities planning & plant operations supervisor, as well as the facility's emergency coordinator, at the time of document review acknowledged the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.
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Based on document review and staff interview, the facility failed to provide an adequate program for relocation of patients to another provider in the event of an emergency. The findings were:

Review of the Emergency Preparedness Plan on 06/09/2021 starting at 1:00 PM revealed that the facility's plan included general language regarding the relocation of patients to other providers in the event of evacuation, or cessation of operations, but no policy or procedure was included to provide detailed information regarding the location of other facilities, or the operations required to relocate and continue services to patients.

Interview with the facilities planning & plant operations supervisor, as well as the facility's emergency coordinator, at the time of document review acknowledged the deficiency. Additional interview revealed that the facility ad verbal agreements with other providers and locations, but this information was not included in the emergency plan.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.
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Based on document review and staff interview, the facility failed to provide policies and procedures for operation under a waiver declared by the secretary. The findings were:

Review of the Emergency Preparedness Plan on 06/09/2021 starting at 1:00 PM revealed that no information was included to provide for the provision of care and treatment at an alternative care site identified by emergency management officials.

Interview with the facilities planning & plant operations supervisor, as well as the facility's emergency coordinator, at the time of document review acknowledged the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.
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Based on document review and staff interview, the facility failed to provide provisions to ensure that emergency power systems are operational during an emergency. The findings were:

Review of the Emergency Preparedness Plan on 06/09/2021 starting at 1:00 PM revealed that the facility had not developed a policy or procedure to ensure that fuel would be available for operation of emergency power systems during an emergency.

Interview with the facilities planning & plant operations supervisor, as well as the facility's emergency coordinator, at the time of document review acknowledged the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.
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Based on document review and staff interview, the facility failed to perform annual fire door inspections in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. Failure to inspect fire doors could result in injury or death during an emergency. The deficiency affected all fire doors within the facility. The findings were:

Document review on 06/09/2021 starting at 11:00 AM could not establish that annual fire door inspections were being performed.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 80, Section: 5.2.1
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Based on observation and staff interview, the facility failed to provide horizontal sliding doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide horizontal sliding doors as required could result in injury or death during an emergency. The deficiency affected two (2) of numerous horizontal sliding doors throughout the facility. The findings were:

Observation on 06/09/2021 at 10:41 AM at the exterior exit of the emergency department revealed a vestibule with interior and exterior horizontal sliding doors. It was observed that each set of doors were provided with deadbolt locks, preventing operation of the breakaway feature in an emergency.

Interview with the facilities planning & plant operations supervisor, as well as the COO, at the time of the observation acknowledged the deficiency, and indicated they were aware of the requirement. They indicated upcoming plans to remove the area from the required means of egress as other routes are available, and the space is only utilized with direct staff supervision.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 7.2.1.4.1(4)(b), and 7.2.1.14
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Based on document review and staff interview, the facility failed to provide testing for battery-powered emergency lighting in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain battery-powered emergency lighting could result in injury or death during an emergency. The deficiency affected all battery-powered emergency lighting within the facility. The findings were:

Document review on 06/09/2021 starting at 11:00 AM revealed that testing of the battery-powered emergency lighting could not be verified. Review of the inspection, testing, and maintenance software utilized by the facility revealed that a reminder would be generated for staff to perform the required testing, but no log or report was generated to track and demonstrate completion of the required testing.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was unaware of the lack of documentation resulting in the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 7.9.3
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Based on observation and staff interview, the facility failed to provide protection for hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain protection for hazardous areas could result in injury or death during an emergency. The deficiency affected one (1) of numerous hazardous areas in the facility. The findings were:

Observation on 06/09/2021 at 9:27 AM in the medical air and compressor room revealed that the existing fire-rated doors were provided with a door closer, but that the closer had been disconnected. As a result, the doors were observed to be resting in the open position.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 8.3.3.3
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Based on observation and staff interview, the facility failed to provide cooking facilities in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to maintain cooking facilities as required could result in injury or death during an emergency, or result in significant damage to the structure. The deficiency affected one (1) of one (1) cooking facilities. The findings were:

Observation on 06/09/21 at 9:54 AM in the kitchen revealed that combustible wall paneling was installed behind the cook line from the floor to the underside of the hood. It was observed that the material appeared to be distorted in areas due to excessive heat. Hoods are required to maintain a minimum clearance of 18 inches to combustible materials.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: NFPA 101, Sections: 19.3.2.5.1, 9.2.3
NFPA 96, Section 4.2.1
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Based on document review and staff interview, the facility failed to maintain, test, and inspect fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain, test, and inspect fire alarm systems as required could result in injury or death in an emergency. The deficiencies affected the fire alarm system. The findings were:

Document review on 06/09/2021 starting at 11:00 AM revealed that alarm notification devices were indicated as tested, but devices were not logged by type, address, and location. Reporting from the fire alarm testing and inspection contractor only indicated a bulk number of devices with an overall pass/fail rating. Additionally, smoke detectors were identified as inspected, but reporting did not indicate testing in regards to smoke entry or calibration. It could not be established that the provided testing satisfied the requirements of NFPA 72. Additional review revealed that the batteries were identified as tested, and were indicated as "OK", but no additional information was provided to indicate that the required semi-annual load voltage testing was performed.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiencies, and indicated he was aware of the requirement.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: NFPA 72, Figure 14.6.2.4
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Based on observation and staff interview, the facility failed to install and maintain sprinkler systems in accordance with the NFPA 101, Life Safety Code, and the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. Failure to install and maintain sprinkler systems as required could result in injury or death during an emergency. The deficiencies affected proper operation of the sprinkler system throughout the facility. The findings were:

1. Observation on 06/09/21 starting at 9:11 AM in the unisex restroom adjacent to receiving revealed a missing ceiling tile within close proximity of the sprinkler head. Missing ceiling tiles can prevent buildup of heat at the ceiling level, and delay activation of the sprinkler system during a fire. Additional observation revealed missing ceiling tiles in numerous areas throughout the facility.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

2. Observation on 06/09/2021 at 10:26 AM in the billing office revealed that metal and glass partition walls had been installed to create three (3) offices and a waiting area. The partition walls extended to within approximately eight (8) inches of the existing ceiling. Further observation revealed that the existing sprinkler heads were located on the office side of the partition walls, and coverage to the waiting area was obstructed.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 13, Sections: 8.5.4, 8.5.5
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Based on Document review and staff interview, the facility failed to maintain portable fire extinguishers in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 10, Standard for Portable Fire Extinguishers. Failure to maintain portable fire extinguishers as required could result in injury or death in an emergency. The deficiency affected all portable fire extinguishers throughout the facility. The findings were:

Document review on 06/09/2021 starting at 11:00 AM revealed that monthly inspection of the portable fire extinguishers could not be verified. Review of the inspection, testing, and maintenance software utilized by the facility revealed that a reminder would be generated for staff to perform the required inspection, but no log or report was generated to track and demonstrate completion of the required inspections.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was unaware of the lack of documentation resulting in the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: NFPA 10, Section: 7.2.1.2
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Based on document review and staff interview, the facility failed to perform monthly operational tests of the elevator firefighters' emergency operations in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain firefighters' emergency operations systems could result in injury or death during an emergency. The deficiency affected all elevators within the facility. The findings were:

Document review on 06/09/2021 starting at 11:00 AM could not establish that monthly testing of the elevator firefighters' emergency operations was being performed.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 9.4.6
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Based on document review and staff interview, the facility failed provide testing for essential electrical systems in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 110, Standard for Emergency and Standby Power Systems . Failure to maintain essential electrical systems could result in injury or death during an emergency. The deficiency affected all essential electrical systems within the facility. The findings were:

Document review on 06/09/2021 starting at 11:00 AM revealed that monthly 30 minute continuous testing of the emergency generator and associated transfer switch monthly testing could not be verified. Review of the inspection, testing, and maintenance software utilized by the facility revealed that a reminder would be generated for staff to perform the required testing, but no log or report was generated to track and demonstrate completion of the required testing.

Interview with the facilities planning & plant operations supervisor at the time of the observation acknowledged the deficiency, and indicated he was unaware of the lack of documentation resulting in the deficiency.

Interview with the COO, who is representing the Board of Directors in the absence of an administrator, at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 110, Sections: 8.4, 8.4.2