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Based on observation, staff interview, and review of facility documents, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the facility. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

482.41 Physical Environment (Cross refer Tag 0700)

Based on observation, review of facility documents, and staff interview conducted on 5/06/16, it was determined that the facility failed to ensure the patient receives care in a safe setting.

Findings include:

Reference: Facility document, Recommended Action Plan, states, "Print Public Notice and Consumer Education and Post at points of access ... Signage on all ice machines, fountains and patient sinks."

1. During a tour of the facility on 5/06/16, the following was observed:

a. Pediatric Room #309 and #312 did not have signage above the sinks.

i. Pediatric Treatment Room #G3030 did not have signage above the sink.

b. The Franklin A restroom, adjacent to the elevator, did not have signage above the sink.

c. Maternity Room #37 did not have signage above the sinks.

d. The Mother/Baby Unit did not have signage above the sinks.

2. These findings were confirmed with Staff #3.

Based on document review and staff interview, it was determined that the governing body failed to ensure the QAPI program involves all hospital departments and services.

Findings include:

Reference #1: Morris County Department of Public Safety, Office of Health Management Notice dated 5/15/15.

1. The QAPI minutes from April 2015 to March 2016 were reviewed.

2. The Governing Body Meeting minutes for January, February, and March 2016 were reviewed.

3. Review of documentation from the Morris County Health Department indicated that issues with the water system were noted on May 15, 2015. Refer to Reference #1.

4. A letter from the Morris County Health Department was sent to the facility stating violations noted on May 15, 2015. Refer to Reference #1.

5. There was no documentation concerning issues with the water system of the hospital being reported through QAPI to the governing body.

6. The above findings were confirmed with Staff #1.

Based on observation and document review on 5/6/16, it was determined that the facility failed to ensure the safety of patients, staff, and the public, is maintained.

Findings include:

1. The facility failed to develop and implement policies and procedures for the maintenance of potable water provided by onsite groundwater wells. Refer to Tag A 0724.

2. The facility failed to develop and implement policies and procedures on how to respond and quickly repair critical physical plant systems in a timely manor. Refer to Tag 0724.

3. The facility failed to ensure compliance with the National Fire Protection Association's Life Safety Code, 2000 edition. Refer to Tag 0709.

Based on observation, it was determined that the facility failed to ensure compliance with the National Fire Protection's Life Safety Code 101, 2000 edition.

Findings include:

Reference: National Fire Protection's Life Safety Code 101, 2000 edition, 101:8.2.4.3.5, Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8

1. On 5/6/16 at 11:00 AM in the presence of Staff #1, the temporary water supply entered the kitchen through the fire rated doors between the kitchen and the corridor. This prevented the doors from self-closing or automatic-closing in the case of a fire.

Based on document review, it was determined that the facility failed to ensure facilities and equipment are maintained to ensure an acceptable level of safety and quality.

Findings include:

Reference #1: Morris County Department of Public Safety, Office of Health Management Notice dated 5/15/15.

Reference #2: New Jersey Department of Environmental Protection Warning Letter dated 9/25/15.

Reference #3: New Jersey Department of Environmental Protection Warning Letter dated 11/25/15.

Reference #4: New Jersey Department of Environmental Protection Warning Letter dated 2/1/16.

Reference #5: New Jersey Department of Environmental Protection Notice of Violation dated 2/19/16.

Reference #6: New Jersey Department of Environmental Protection Notice of Violation dated 3/2/16.

1. On 5/6/16, a review of a Notice of Violation issued by the Morris County Department of Public Safety, Office of Health Management as a result of a joint Sanitary Survey with the New Jersey Department of Environmental Protection as required, by the Federal Ground Water Rule 40 CFR 141.400 et seq. after the facility failed to collect water quality parameters in the distribution system as required in the 7/11/14 Corrosion Control Treatment recommendation approval letter. The following violations were identified:

a. Failure to develop and implement a Stage 2 DBP monitoring plan. Refer to Reference #1.

b. Failure to have a lead and copper sampling pool. Refer to Reference #1.

c. Failure to have a no-flow switch in place to prevent the feeding of chemical solution upon water cessation. Refer to Reference #1.

d. Failure to have a O & M Manual for the treatment devices on site. Refer to Reference #1.

e. Failure to employ a licensed operator holding the appropriate class license. Refer to Reference #1.

f. Failure to timely submit a completed monthly operating report. Refer to Reference #1.

g. Failure of the licensed operator to ensure that the system is operated and maintained properly. Refer to Reference #1.

h. Failure to regularly inspect, clean, and maintain water storage tanks to minimize potential contamination of drinking water. Refer to Reference #1.

2. On 5/6/16, a review of a Warning Letter dated 9/25/15 issued by the New Jersey Department of Environmental Protection, provided evidence that the facility failed to take corrective action required from the initial Sanitary Survey conducted on 5/15/15. Refer to Reference #2.

3. On 5/6/16, a review of a Warning Letter dated 11/25/15 issued by the New Jersey Department of Environmental Protection, provided evidence that the facility failed to take corrective action required from the re-inspection on 9/25/15 of the Sanitary Survey conducted on 5/15/15. Refer to Reference #3.

4. On 5/6/16, a review of a Warning Letter dated 2/1/16 issued by the New Jersey Department of Environmental Protection, provided evidence that the facility failed to take corrective action required from the re-inspection on 11/17/15 of the Sanitary Survey conducted on 5/15/15. Refer to Reference #4.

5. On 5/6/16, a review of a Notice of Violations issued to the facility by the New Jersey Department of Environmental Protection, provided evidence that as of 2/19/16, violations from the 5/15/15 survey were not corrected. Refer to Reference #5.

6. On 5/6/16, a review of a Notice of Violations issued to the facility by the New Jersey Department of Environmental Protection, provided evidence that as of 3/2/16, violations from the 5/15/15 survey were not corrected. Refer to Reference #6.