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Based on record review and interview, the hospital failed to ensure development, maintenance, and annual review of a facility-based community-based risk assessment using an all hazards approach as required.

Findings:

Record review of the emergency preparedness plan showed the facility did not annually maintain and review the facility-based and community-based risk assessments that utilized an all hazards approach. An annual risk assessment for the facility emergency preparedness plan did not exist for 2017-2018.

On 07/24/19 at 02:17 pm, the surveyor asked Staff L for written documentation of the facility's risk assessments and associated emergency preparedness strategies. Staff L stated the risk assessment had not been updated annually since 2014. The annual review and approval documentation did not exist. Staff L stated the facility is in process of writing policies to ensure compliance.

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address policies and procedures regarding the sheltering in place of residents, staff and volunteers who remain in the facility during an emergency or disaster.

Findings:

On 07/23/19 at 2:10 pm, during the review of the Facility's Emergency Preparedness plan showed that they lacked a policy regarding the sheltering in place of residents, staff and volunteers who will remain in the facility during an emergency. Facilities are required to have policies and procedures for sheltering in place which align with the facility's risk assessment and are expected to include the criteria for determining which patients and staff would be sheltered in place.

On 07/23/19 at 2:12 pm, during an interview the surveyor requested Staff L for the shelter in place policy and procedures, Staff L stated the facility is in the process of updating and revising the policies and procedures.

Based on record review and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with section 1135 of the act in provision of care and treatment.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster.


On 07/24/19 at 10:50 am, the surveyor asked Staff L if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff L stated the facility is in process of updating policies to ensure compliance with the development of the 1135 waiver policy. The document did not exist.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 07/24/19 at 2:43 pm, surveyor observed the ABC fire extinguisher in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher.

On 07/24/19 at 2:47 pm, Staff L stated he would get with their fire service vendor to get the appropriate placard(s) for the fire extinguishers that are installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview the facility failed to ensure barrel latches were not installed within the facility.

Findings:

On 07/24/19 at 4:58 pm, the surveyor observed a barrel latch on the bathroom door near the conference room.

On 07/24/19 at 5:00 pm, the surveyor asked Staff L why the barrel latch was on the door and Staff L stated the barrel latch would be taken off.

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the facility fire drills for 2017 and 2018 did not document a transmission of a fire alarm signal for every fire drill completed.

On 07/23/19 at 3:54 pm, the surveyor asked Staff L if the facility contacted fire alarm company to verify a transmission of fire alarm signal. Staff L stated the fire alarm company was contacted but did not document the call. Staff L stated the transmission of alarm signal would be added to the fire drill documentation.

Based on observation and interview the facility failed to properly store decorations in a protected area when not displayed.

Findings:

On 07/24/19 at 4:59 pm, during the tour of the facility the surveyor observed in the Physical Therapy room bathroom
decorations, plastic bins, and space heaters stored inside a shower.

On 07/24/19 at 5:00 pm, the surveyor asked Staff L if the facility stored decorations in the shower area. Staff L stated
the decorations belonged to facility staff. The surveyor informed Staff L the decorations would need to be stored in a protected area when not being displayed and according to NFPA guidelines.

Decorations meet NFPA 701.
Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4).
The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present.
19.7.5.6

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2018 were not completed and the documentation did not exist.

On 07/23/19 at 2:33 pm, the surveyor asked Staff L for the annual fire rated door assembly inspections. Staff L stated he was unaware of the new requirement and the documentation does not exist.

Based on observation and interview the facility failed to ensure space heaters used within the facility had documentation that the heating elements did not exceed 212 degrees Fahrenheit as required.

Findings:

On 07/24/19 at 4:08 pm, the surveyor observed space heaters in staff office.

On 07/24/19 at 4:08 pm, the surveyor asked Staff L if the facility had the manufacturers documentation indicating the heating elements to each of the space heaters do not go over 212 degrees Fahrenheit. Staff L did not provide the documentation as it did not exist.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed.

On 07/24/19 at 2:35 pm, the surveyor asked Staff L for the EES and Medical Gas building system risk assessments. Staff L stated he was aware of this requirement and the facility did not have the EES and medical gas building system risk assessments. The documentation does not exist.

Based on record review and interview the facility failed to ensure impedance testing/maintenance to hospital grade electrical receptacles in patient care areas were placed on a preventative maintenance program based on intervals defined by documented performance data as required.

Findings:

Record review showed the facility did not conduct Impedance testing for patient care areas in accordance with NFPA 99 as required.

On 07/24/19 at 6:20 pm, the surveyor asked Staff L for documentation of the impedance testing for patient care areas. Staff L stated he was unaware of requirement, but would get the testing scheduled to be completed.

Based on record review and interview the facility failed to ensure the annual two hour load bank testing, and thirty six month four hour load bank testing was conducted on the emergency generator as required.

Findings:

Record review showed the facility has not conducted annual two hour load bank testing for 2015, 2016, and 2017; and the last 36 month four hour load bank testing as the documents do not exist.

On 07/24/19 at 06:17 pm, the surveyor asked Staff L to provide the annual two hour load bank testing for 2015, 2016, and 2017; and the last 36 month four hour load bank test. Staff L stated the tests requested have not been completed since 2009 because the previous CEO did not allow the load bank testing to be conducted because of the cost.