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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 facility emergency preparedness plan showed the facility did not annually review it as required. The facility emergency preparedness plan also showed it was not written from a all hazards approach as required and only listed "tornado and large fire".

On 06/12/18 at 11:17 am the surveyor asked Staff C for the facility's emergency preparedness plan with the all hazards approach as required by CMS. Staff C stated the one the surveyor already reviewed is the only one the facility has. The surveyor explained the one reviewed lists "tornado and large fire" and is not written from an all hazards approach as required. Staff C stated they will correct that.

Based on record review and interview the facility failed to ensure development of the facility emergency preparedness communication plan.

Findings:

Record review of the emergency preparedness plan showed it did not contain a communication plan as required.

On 06/12/19 at 11:17 am the surveyor asked the Staff C for the emergency preparedness communication plan. Staff C stated it has not been developed as the position has just been turned over to her and she is still getting organized.

Based on record review and interview the facility failed to ensure monthly and yearly testing of emergency lighting as required.

Findings:

Record review showed the facility was doing weekly checks of emergency lighting but there was no documentation of the duration of the functional testing time being completed. The facility documentation did not include yearly testing of emergency lighting.

On 06/13/19 at 11:13 am the surveyor asked staff C to explain how they complete the monthly and yearly testing of the battery backed up emergency lighting. Staff C stated they do weekly testing of emergency lighting for approximately fifteen seconds. The surveyor asked where do you document the length of time you test the emergency lights. Staff C stated they haven't documented it but will start. The surveyor asked where the documentation is for the yearly testing of the emergency lighting. Staff C stated they didn't know there was yearly testing but will start that since they now know it is a requirement.


7.9 Emergency Lighting.
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.

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 06/12/19 at 9:40 am two K class fire extinguishers were observed in the kitchen with no placards posted next to them to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 06/12/19 at 9:40 am Staff C stated he would get with their fire service vendor to get the appropriate placard(s) for each of 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 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 2019, and 2018 did not document a transmission of a fire alarm signal for every fire drill completed.

On 06/12/19 at 1:07 pm the surveyor stated to Staff C the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff C stated they would add that to the fire drill documentation.

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 06/12/18 at 9:42 am the surveyor asked Staff C for the annual fire rated door assembly inspections. Staff C stated the inspection was not completed for 2018 and the documentation does 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. They do not exist.

On 06/12/19 at 9:35 am the surveyor asked Staff C for the EES and Medical Gas building system risk assessments, and Staff C stated he would check. Staff C came back a time later and stated they do not have the EES and medical gas building system risk assessments. Staff C stated they will get them completed.

Based on record review, and interview the facility failed to ensure annual impedance testing of patient care related electrical receptacles as required.

Findings:

Record review showed the facility did not have the annual impedance testing of the patient care related electrical receptacles.

On 06/12/19 at 10:43 am the surveyor asked staff C for the annual impedance testing inspection of patient care related electrical receptacles for patient treatment areas. Staff C stated the only are would be the treatment room and they did not do the testing but will install hospital grade receptacles so it can be done every two years on a preventative maintenance program to save money.