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Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include at a minimum, (1) The provision of subsistence needs for staff and residents, whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical, and pharmaceutical supplies. (ii) Alternate sources of energy to maintain - (A) Temperatures to protect resident health and safety and for the safe and sanitary storage of provisions; (B) Emergency lighting; (C) Fire detection, extinguishing, and alarm systems; and (D) Sewage and waste disposal in accordance with 42 CFR 482.73(b)(1). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 2:00 p.m., the subsistence needs documentation for the emergency preparedness program was incomplete and was missing the following:
a) Emergency food and water policies.
b) Emergency temperatures policy to protect resident health and safety.
c) Emergency Sewage and waste disposal outage policies.
Based on interview at the time of record review, the Quality Improvement Assistant stated the aforementioned policies could not be found.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include a system to track the location of on-duty staff and sheltered patients in the facility's care during and after an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the facility must document the specific name and location of the receiving facility or other location in accordance with 42 CFR 482.73(b) (2). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 2:05 p.m., a policy and procedure that includes a system to track the location of on-duty staff and patients in the facility's care during and after an emergency was not available for review. Based on interview at the time of record review, the Quality Improvement Assistant stated the facility did not have a policy and procedure for tracking patients and staff during an emergency.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness plan (EPP) include a means to shelter in place for patients, staff, and volunteers who remain in the facility in accordance with 42 CFR 482.475(b)(4). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 2:10 p.m., the facility's EPP did not address procedures to shelter in place for patients, staff, and volunteers. Based on interview at the time of records review, the Quality Improvement Assistant stated there was not an individual sheltering in place policy.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures (EPP) include the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency in accordance with 42 CFR 482.72(b)(6). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 2:00 p.m., the provided EPP did not address the use of volunteers in an emergency. Based on interview at the time of records review, the Quality Improvement Assistant stated there was not a policy on the use of volunteers in an emergency provide in the EPP.


This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures (EEP) include the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials in accordance with 42 CFR 482.72(b) (8). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 2:20 p.m., a policy and procedure for the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act was not available for review. Based on interview at the time of records review, the Quality Improvement Assistant stated there was not a policy addressing the role of the facility under a waiver declared by the Secretary in the EPP.


This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to conduct annual training for the Emergency Preparedness Program (EPP). The facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; (ii) Provide emergency preparedness training at least annually; (iii) Maintain documentation of all emergency preparedness training; (iv) Demonstrate staff knowledge of emergency procedures in accordance with 42 CFR 482.73(d) (1). This deficient practice could affect all occupants in the facility.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 2:22 p.m., no documentation of annual EEP training and no documentation to show staff could demonstrate knowledge of the EPP was available for review. Based on an interview at the time of records review, the Quality Improvement Assistant stated annual training was not conducted.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to conduct exercises to test the emergency plan at least twice per year. The facility must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
a. When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
b. If the facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the facility is exempt from engaging its next required full-scale in a community-based or individual, facility-based full-scale functional exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
a. A second full-scale exercise that is community-based or an individual, facility-based functional exercise.
b. A mock disaster drill; or
c. A tabletop exercise or workshop that is led by a facilitator that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the facility's emergency plan, as needed in accordance with 42 CFR 482.475(d)(2). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 2:30 p.m.,
the following was not available for review:
a) No documentation of the current COVID-19 actual emergency was available for review.
b) No documentation of an additional annual exercise that was a second full-scale exercise that is community-based, a facility-based functional exercise, a mock disaster drill, a tabletop exercise, or a workshop was available for review.
Based on interview at the time of records review, the Quality Improvement Assistant stated the facility is using the current natural COVID-19 emergence as one of the requirements, but the documentation has not been written. Also, a second exercise was not completed within the last year.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g., duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all patients in the facility.

Findings include:

During records review with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 at 10:29 a.m., no documentation was provided regarding a visual inspection of the fire alarm system six months prior to the annual fire alarm inspection conducted on 11/12/20. Based on interview at the time of records review, the Maintenance Forman stated a visual inspection of the fire alarm system six months prior to the annual fire alarm inspection was not conducted.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 1:14 p.m., the fire watch plan failed to include contacting the Indiana State Department of Health via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. Based on interview during the record review, the Quality Improvement Assistant acknowledged the fire watch documentation provided stated to contact the Indiana State Department of Health, and not via the ISDH Gateway link or at the e-mail address listed above.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to provide 1 of 1 correct written policies in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.6 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. A.15.5.2 (4) (b) states a fire watch should consist of trained personnel who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. This deficient practice could affect all occupants in the facility.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 1:14 p.m., the fire watch plan failed to include contacting the Indiana State Department of Health via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. Based on interview during the record review, the Quality Improvement Assistant acknowledged the fire watch documentation provided stated to contact the Indiana State Department of Health, and not via the ISDH Gateway link or at the e-mail address listed above.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect all patients in the facility.

Findings include:

Based on observations with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 at 12:09 p.m., in the smoke barrier near resident room 101 there was a two-inch unsealed hole and a small gap around wires. Based on interview at the time of observation, the Maintenance Forman agreed there were unsealed gaps and holes in the 101 smoke wall and provided the measurements of the unsealed penetrations.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review, observation, and interview; the facility failed to ensure 15 of 15 fire dampers in the facility were inspected and provided necessary maintenance. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients in the facility.

Findings include:

Based on observation with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 between 11:00 a.m. and 1:00 p.m., there were smoke/fire dampers noted in the HVAC duct work throughout the building. Based on records review at 10:30 a.m., no documentation of an inspection for the smoke/fire dampers in the facility was available for review. Based on interview at the time of records review and observation, the Maintenance Forman stated there are about 15 smoke/fire dampers in the facility and no inspection has been conducted since the dampers were installed over six years ago.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review and interview, the facility failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to fire department.
3. Emergency phone call to fire department
4. Response to alarms.
5. Isolation of fire.
6. Evacuation of immediate area.
7. Evacuation of smoke compartment.
8. Preparation of floors and building for evacuation.
9. Extinguishment of fire.
This deficient practice could affect all patients in the facility.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 1:17 p.m., the provided facility's fire safety plan did not address the following items:
a) Extinguishment of fire. The fire safety plan did not indicate how use a fire extinguisher and did not address the types of fire extinguishers in the facility.
b) Evacuation of smoke compartment. The facility did not address how to evacuate a smoke compartment nor identify the smoke barrier walls and smoke compartments in the facility.
c) Emergency phone call to fire department. The facility did not address calling the fire department after activation of the fire alarm system or discovery of fire.
Based on interview at the time of records review, the Quality Improvement Assistant looked through the fire safety plan and stated the aforementioned items were not in the provided plan.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on observation, record review and interview, the facility failed to ensure the hospital grade electrical receptacles in 16 of 16 patient sleeping rooms were tested at least annually. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.1 states where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. Additionally, Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). This deficient practice could affect all patients in the facility.
Findings include:

Based on observations during a tour of the facility with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 between 11:00 a.m. and 1:00 p.m., the facility's 16 patient sleeping rooms contained four hospital grade electrical receptacles. Based on records review at 11:30 a.m., no documentation was available to show electrical receptacles in patient sleeping rooms were tested after initial installation, replacement, or servicing of the device. Based on interview at the time of the observation and records review, the Maintenance Forman confirmed all of the electrical receptacles in the patient sleeping rooms were hospital-grade and stated testing per NFPA 99, Receptacle Testing requirements has not been completed.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

#1. Based on record review and interview, the facility failed to maintain 1 of 1 Emergency Power Standby System in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Section 8.4.9, as required by NFPA 99 Health Care Facilities Code, Section 6.4.1.1.6.1. NFPA 110 Section 8.4.9 states that all Level 1 Emergency Power Systems shall be tested at least once within every three years. Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 hours. NFPA 99 Section 6.4.1.1.6.1 states that Type 1 and Type 2 essential electrical system power sources shall be classified at Type 10, Class X, Level 1 generator sets. This deficient practice could affect all patients in the facility.

Findings include:

During records review with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 at 11:14 a.m., documentation of a four-hour continuous run under load for the emergency generator conducted within the last 36 months was not provided for review. Based on interview at the time of records review, the Maintenance Forman stated a four-hour continuous run under load was not conducted in the past 36 months.

#2. Based on record review and interview, the facility failed to ensure an annual fuel quality test was performed for 1 of 1 facility's diesel-powered generator. NFPA 99, Health Care Facilities Code, 2012 Edition Section 6.5.4.1.1.2 states Type 2 EES (Essential Electrical System) generator sets shall be inspected and tested in accordance with Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, 2010 Edition, Chapter 8. NFPA 110, Section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards. This deficient practice could affect all patients in the facility.

Findings include:

During records review with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 at 11:19 a.m., no documentation of an annual fuel quality test for the diesel generator was available for review. Based on interview at the time of records review, the Maintenance Forman stated the facility does have a diesel generator but was unaware of the fuel quality testing requirements and did not have the fuel tested.

The findings were reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.