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Based on document review and interview, the facility failed to maintain the emergency preparedness (EP) plan. This was evidenced by the failure to provide a process for emergency preparedness plan (EPP) collaboration. This affected all patients, and could result in ineffective emergency planning.

Findings:

During document review and interview with the Director of Plant Operations (DPO) on 5/24/23, the EP plan was requested.

At 4:29 p.m., the facility failed to provide upon request written documentation of the facility's process for collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on record review and interview, the facility failed to develop and implement policies and procedures that support the execution of the emergency plan (EP). This was evidenced by incomplete policies and procedures for subsistence needs for staff and patients. This could result in not having the necessary planning and preparation in place to adequately protect the health and safety for patients, and affected all patients.

Findings:

During record review and interview with the Director of Plant Operations (DPO) on 5/24/23, the policies and procedures were requested.

At 4:29 p.m., the facility failed to provide upon request the policy and procedure for subsistence needs for staff and patients, whether they evacuate or shelter in place for medical/pharmaceutical supplies, temperatures to protect patient health and safety and for the safe and sanitary storage of provisions, emergency lighting, and sewage and waste disposal.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure for tracking of on-duty staff during an emergency. This affected all patients, and could result in an ineffective (EP) plan.

Findings:

During document review and interview with the Director of Plant Operations (DPO) on 5/24/23, the EP policies and procedures were requested.

At 4:29 p.m., the facility failed to provide upon request the policy policy and procedure for tracking of patients and on-duty staff during an emergency.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure regarding evacuation from the facility during an emergency. This affected all patients, and could result in an ineffective (EP) plan.

Findings:

During document review and interview with the Director of Plant Operations (DPO) on 5/24/23, the EP plan was requested.

At 4:29 p.m., the facility failed to provide upon request the policy and procedure regarding safe evacuation from the facility, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation locations; and primary and alternate means of communication with external sources of assistance.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested document to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide the policy and procedure for sheltering. This affected all patients, and could result in an ineffective (EP) plan.

Findings:

During document review and interview with the Director of Plant Operations (DPO) on 5/24/23, the EP policies and procedures were requested and reviewed.

At 4:29 p.m., the policy and procedure for how the facility would provide a means to shelter in place for patients, staff, and volunteers who remain at the facility during the event of an emergency was not provided upon request.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure for a medical documentation. This affected all patients, and could result in an ineffective (EP) plan.

Finding:

During document review and interview with Director of Plant Operations (DPO) on 5/24/23, the EP policies and procedures were requested and reviewed.

At 4:19 p.m., there was no policy and procedure outlining the facility's medical record documentation system to preserve patient information, protect confidentiality of patient information, and secure and maintain availability of records in the event of an emergency.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure regarding arrangements with other facilities. This affected patients, and could result in an ineffective (EP) plan.

Findings:

During document review and interview with the Director of Plant Operations (DPO) on 5/24/23, the EP policies and procedures were requested and reviewed.

At 4:29 p.m., there was no policy and procedure in the EP regarding arrangements with other facilities to receive patients in the event the facility is not able to care for them during an emergency.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) Plan. This was evidenced by the failure to provide a communications plan with the facility's method for sharing information. This affected all patients, and could result in ineffective emergency planning.

Findings:

During document review and interview with the Director of Plant Operations (DPO) on 5/24/23, the EP plan was requested.

At 4:29 p.m., a review of the EP revealed that the communication plan failed to provide a method for sharing information and medical documentation for patients, as necessary, with other health providers, to maintain the continuity of care.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) Plan. This was evidenced by the failure to a plan for sharing information on occupancy/needs. This affected all patients, and could result in ineffective emergency planning.

Findings:

During document review and interview with the Director of Plant Operations (DPO) on 5/24/23, the EP plan was requested and reviewed.

At 4:29 p.m., the facility failed provide upon request an updated communications plan that included a means of providing information about the facility's needs, and its ability to provide assistance to the authority having jurisdiction, the incident command center, or designee.

Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on record review and interview, the facility failed to develop and maintain the emergency preparedness (EP) training and testing programs. This was evidenced missing initial and subsequent EP training documents. This could result in not having the necessary planning and preparation in place to adequately protect the health and safety of patients and affected two of two floors.

Findings:

During record review and interview with the Director of Plant Operations (DPO) on 5/24/23, the emergency preparedness training and testing programs were requested.


At 4:29 p.m., the facility failed to provide upon request records of the EP training program for initial and subsequent training on EP. Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on record review and interview, the facility failed to develop and maintain the emergency preparedness training and testing programs. This was evidenced by the absence of a full-scale community-based exercise and a facility-based exercise. This could result in not having the necessary planning and preparation in place to adequately protect the health and safety of patients and affected two of two floors.

Findings:

During record review and interview with the Director of Plant Operations (DPO) on 5/24/23, the emergency preparedness training and testing programs were requested.

At 4:29 p.m., the facility failed to maintain records for a full-scale community-based exercise and a facility-based exercise that was performed during the past year. Upon interview, the DPO stated that he was not aware of where the EP plan was located and would provide the requested documents to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested EP documents.

Based on observation and interview, the facility failed to maintain the building construction. This was evidenced by an unsealed penetration in a wall. This affected one of two floors and could result in the spread of fire and smoke in the event of a fire.

Findings:

During a tour of the facility and interview with the Director of Plant Operations (DPO) on 5/24/23, the ceiling and walls were observed.

At 2:35 p.m., an unsealed penetration approximately one inch by two inches was observed on the second floor in the IT room with data cables running through the penetration. Upon interview, the DPO stated that it was an oversight to not seal the penetration with fire-resistive caulking.

Based on observation and interview, the facility failed to maintain the emergency lights. This was evidenced by an emergency light that failed to remain illuminated when tested. This affected one of two floors and could result in delayed egress in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.9 Emergency Lighting
19.2.9.1 Emergency Lighting shall be provided in accordance with Section 7.9
7.9.3 Periodic Testing of Emergency Lighting Equipment.7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility and interview with the Director of Plant Operations (DPO) on 5/24/23, the emergency lights were observed and tested.

At 2:41 p.m., the emergency light in Exam Room 2 on the first floor failed to remain illuminated when tested. Upon interview, the DPO stated that the battery was no longer functioning.

Based on observation and interview, the facility failed to maintain the exit signs. This was evidenced by battery-operated exit signs that failed to remain illuminated when tested. This affected one of two floors and could result in delayed egress in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition

19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance
with 7.9.3.1.3.

7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:

(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility and interview with the Director of Plant Operations (DPO) on 5/24/23, the battery-operated exit signs were observed and tested.

1. At 1:58 p.m., the battery-operated exit sign on the second floor in Business Services by the physical therapy corridor failed to remain illuminated when tested. Upon interview, the DPO stated that the battery was no longer functioning.

2. At 1:58 p.m., the battery-operated exit sign on the second floor next to the medical records room failed to remain illuminated when tested. Upon interview, the DPO stated that the battery was no longer functioning.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that were obstructed from closing. This could result in the passage of smoke in the event of a fire, and affected one of two floors.

Findings:

During a tour of the facility and interview with the Director of Plant Operations (DPO) on 5/24/23, the corridor doors were observed.

1. At 1:54 p.m., the corridor door with a self-closing device to the Physical Therapy Exam room on the second floor was observed with a door wedge that obstructed the door from self-closing. Upon interview, the DPO stated that staff place the door wedge to allow easy access to the room.

2. At 1:56 p.m., the corridor door with a self-closing device to the Physical Therapy Room on the second floor failed to latch when allowed to self-close. The door was tested three times and failed to latch on all three occasions. Upon interview, the DPO stated that the door latch did not line up with the strike plate.

3. At 2:15 p.m., the corridor door to the linen room on the second floor failed to latch when tested. The strike plate was observed with tape that prevented the door from latching. Upon interview, the DPO stated that staff placed the tape to allow easy access to the room.

Based on observation and interview, the facility's kitchen staff failed to demonstrate basic knowledge on how to utilize the fixed fire suppression system. This was evidenced by a kitchen staff member that was unable to demonstrate how to use the fixed fire suppression system and the Class K fire extinguisher in the kitchen area. This affected one of two floors, and could result in the delay of fire extinguishment in the event of a kitchen fire.

Findings:

During a tour of the facility and interview with the Director of Plant Operations (DPO) on 5/24/23, the kitchen area was observed and staff were interviewed.

At 2:32 p.m., a kitchen staff member was interviewed regarding how to utilize the fixed fire suppression system to extinguish a grease-based fire. The Kitchen Staff member stated that she would utilize the Class K fire extinguisher before activating the fixed fire suppression system. The kitchen staff member was unable to demonstrate how to activate the fixed suppression system manually. Upon interview, the DPO stated that training was provided routinely to all staff.

Based on record review and interview, the facility failed to perform fire drills. This was evidenced by missing fire drill records. This affected of two of two floors and and could result in the lack of staff knowledge in the event of a emergency.

Findings:

During record review and interview with the Director of Plant Operations (DPO) on 5/24/23, the fire drill records were requested and reviewed.

At 2:26 p.m., the facility failed to provide upon request documentation for the AM and PM fire drills for fourth quarter of 2022. Upon interview, the DPO stated that the documents were misplaced.

Based on observation and interview, the facility failed to maintain the portable heater. This was evidenced by a portable heater that was located in close proximity to combustible materials. This affected one of two floors, and could result in a fire.


During a tour of the facility with the Director of Plant Operations (DPO) on 5/24/23, a portable heater in the Director of Lab office was observed.

At 2:02 p.m., a portable heater was observed approximately two inches away from paper storage in the Director of Lab office on the second floor. The manufacturer warning label stated "Keep combustible material such as furniture, papers, clothes, and curtains at least 3 feet (0.9m) from the front of the heater and away from the sides and rear."

Upon interview, the DPO stated that he was not aware that the Director of Lab had a portable heater in the office.

Based on document and interview, the facility failed to maintain the Emergency Power Supply System (EPSS). This was evidenced by the absence the annual fuel quality test for the diesel EPSS. This affected two of two floors, and could result in a malfunction of the EPSS in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1.

9.1.3.1 Emergency Generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition.

Chapter 8 Routine Maintenance and Operational Testing

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

Findings:

During document review and interview with the Director of Plant Operations (DPO) on 5/24/23, the EPSS documentation was requested and reviewed.

At 4:12 p.m., the facility failed to provide upon request documentation the Annual fuel quality test for the diesel EPSS.

Upon interview, the DPO stated that the annual Fuel Quality Test was performed, however he had not received the report from the vendor. The DPO stated that he would provide the requested document to the California Department of Public Health by 12 p.m. on 5/25/23.

On 5/25/23 at 12 p.m., CDPH did not receive the requested annual fuel quality test documentation.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment . This was evidenced by electrical panels that were missing circuit identification and an unused openings that was not sealed. This affected one of two floors and could result in a delay in identification of individual circuits.

NFPA 101, Life Safety Code, 2012 Edition

19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1 Utilities.
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

408.4 Field Identification Required.
(A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy.

408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure.

Findings:

During a tour of the facility and interview with the Director of Plant Operations (DPO) on 5/24/23, the electrical wiring and equipment was observed.

1. At 2:13 p.m., Electrical Panel LG in the Staff Nurse's lounge room on the second floor was observed without identification for circuits 5, 7, 9, 11, and 12. Upon interview, the DPO stated that he was unaware of the missing identification.

2. At 2:30 p.m., Panel B located next to the mail room on the second floor was observed with an unprotected opening in space 9. Upon interview, the DPO stated that he was unaware of why the unprotected opening was missing a spare blank.

Based on observation and interview, the facility failed to maintain the electrical equipment and wiring. This was evidenced by the non-compliant use of power strips. This affected two of two floors and could result in an electrical fire.

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

Chapter 9 Building Service and Fire Protection Equipment
9.1 Utilities.
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
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure
(7) Where subject to physical damage

Findings:

During a facility tour and interview with Director of Plant Operations (DPO) on 5/24/23, the electrical equipment and wiring was observed.

1. At 2 p.m., the Director of Revenue Cycle (DRC) office on the second floor was observed with a relocatable power tap that was connected to another relocatable power tap next to the DRC desk. Upon interview, the DPO stated that the DRC connected the two relocatable power taps together.

2. At 2:39 p.m., the Infection Control Room on the second floor was observed with a relocatable power tap that was connected to another relocatable power tap along the north-west wall. Upon interview, the DPO stated that staff had connected the two relocatable power taps together.

Based on observation and interview, the facility failed to maintain the gas equipment. This was evidenced by two oxygen cylinder e-tanks that were stored on top of oxygen cylinders in the Oxygen Storage enclosure. This affected the western exterior of the building and could result in damage to the oxygen cylinders.


NFPA 99, Health Care Facilities Code, 2012 edition

11.6.2.3 Cylinders shall be protected from damage by means
of the following specific procedures:

(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility and interview with the Director of Plant Operations (DPO) on 5/24/23, the Oxygen Storage enclosure was observed.

At 1:45 p.m., two cylinder e-tanks were observed unsecured and laying horizontal across 24 e-tanks in the oxygen storage enclosure located in the Taylor street exterior of the building. Upon interview, the DPO stated that he was unaware of why the two e-tanks were stacked on top of the other e-tanks.