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Based on observation and interview, the Facility failed to maintain emergency lighting in accordance with 7.9.

Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 02/13/18, during the inspection, 4 out of 4 emergency lights that were tested did not function properly.

This deficient practice was confirmed by the Clinic Manager at the time of discovery.

Based on observation and interview, the Facility failed to maintain emergency lighting in accordance with 7.9.

Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 02/13/2018, during documentation review, it was revealed that there was no documentation to show that the emergency lights within the Operating Rooms had received a 30 second monthly test and a 90 minute annual test.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Based on observation and interview, the Facility failed to ensure doors protecting corridor openings were in operable condition.


Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 02/13/2018, documentation review revealed that not all the required information is being documented during the Annual Fire and Smoke Door Inspection per NFPA 80.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to maintain a Evacuation and Relocation Plan according to the 2012 Life Safety Code.

Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2.
18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 02/13/2018, during documentation review, it was discovered that the fire emergency plan does not include a statement that directs staff to call 911 upon discovery of smoke or fire.

This deficient practice was verified by the Facility Maintenance Director.

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

FINDINGS INCLUDE:

Based on observation and interview, the Facility failed to comply with (NFPA 99). On facility tour between 10:00 AM and 1:00 PM on 02/13/2018, it was revealed that not all of the testing procedures were being conducted during the electric receptacle testing. The electrical receptacles must receive the following inspections:

1.The physical integrity of each receptacle shall be confirmed by visual inspection.
2. The continuity of the grounding circuit in each electrical receptacle shall be verified.
3. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
4. The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

This deficient practice was verified by the Facility Maintenance Director.

Gas Equipment - Qualifications and Training of Personnel
Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.
11.5.2.1 (NFPA 99)

FINDINGS INCLUDE:

Based on observation and documentation review,between 10:00 AM and 1:00 PM on 02/13/2018, documentation could not be located to show that all staff that handle gas cylinders have received safety training guidelines and usage requirements of gas cylinders per NFPA 99.

This deficient practice was verified by the Facility Maintenance Director.