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Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR 482.15, by failing to address all criteria for the means to shelter in place for patients, staff, and volunteers who remain in the facility. This deficient practice affects all occupants of the facility. The facility had a capacity of 49 and a census of 22 patients at the time of the survey.

Findings include:

Record review and interview on 09/29/20, at 2:04 p.m., revealed the facility's emergency plans did not include a means for sheltering all patients, staff, and volunteers who remain in the facility in the event that an evacuation cannot be executed. In certain disaster situations (such as tornadoes), sheltering in place may be more appropriate as opposed to evacuation and would require a facility to have a means to shelter in place for such emergencies. The facility did not have documented policies and procedures for sheltering in place which align with the facility's risk assessment.

The Maintenance Supervisor verified these findings during the survey process.

Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR 482.15by failing to incorporate policies and procedures in its emergency plan describing the facility's role under a waiver in accordance with Social Security Act, Section 1135, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice affects all occupants of the facility. The facility had a capacity of 49 a census of 22 patients at the time of the survey.

Findings include:

Record review and interview on 09/29/20 at 1:56 p.m., revealed the facility's emergency preparedness policies and procedures did not specifically address the facility's role in emergencies where the Health and Human Services Secretary declares a public health emergency. The emergency preparedness plan failed to demonstrate the facility's general awareness of the 1135 process, including the following:

1) Knowledge of how to request a waiver and who to contact (contact information) in the event an 1135 waiver needs to be requested;

2) The circumstances when an 1135 waiver might be granted based on the risk analysis

3) How they would operate under and outline the responsibilities during the duration of the waiver period

4) How they would plan jointly on issues related to staffing, equipment, and supplies.

The Maintenance Supervisor verified this finding during the survey process.

Based on observation and interview, this facility is not providing clearly recognizable exit access and exit doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 7.5.2.2. This deficient practice affects all patients, staff, and visitors on 2nd Floor. This facility had a capacity of 49 and a census of 22 patients at the time of the survey.

Findings include:

Observation on 09/29/20, between 12:59 p.m., revealed the Medical/Surgery 50's Hallway had an exit door labeled with the following sign: "Do not enter, this door is locked and alarmed". This door had visible panic/fire exit hardware and an exit signs above the door. The facilities director stated that the door is only alarmed and not actually locked.

This observation was confirmed by the Facilities Director during the survey.

Based on observation and interview, this facility is not providing a delayed-egress locking arrangement in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.2.2.2.4 and 7.2.1.6.1.1. This deficient practice affects all residents, staff, and visitors in the OB Unit. This facility had a capacity of 49 and a census of 22 patients at the time of the survey.

Findings include:

Observation and interview on 09/29/20 at 1:09 p.m., revealed the delayed egress locking door in OB did not have any signage instructing occupants to "Push Until Alarm Sounds Door Can Be Opened In 15 Seconds" or identifying the doors as doors equipped with a special locking arrangement.

This observation was verified by the Facilities Director.


NFPA 101, 2012 edition, 7.2.1.6.1 Delayed-Egress Locking Systems.

(4)*A readily visible, durable sign in letters not less than 1 in. high and not less than 18 in. in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 10.5.5.3 by ensuring the fire alarm dedicated branch circuit be mechanically protected. This deficient practice affects all occupants of the building, including patients and staff.

Findings include:

Observation on 09/29/20 at 3:42 p.m., revealed the fire alarm breaker, located in electrical Panel by the main fire panel in the basement was not secured with a mechanical lock.

This was not verified by the Facilities Director as he was not present at the clinic during the survey.

Based on observation and interview, the facility failed to install, test, and maintain the fire alarm system within the building in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code and Signaling Code, 2010 edition. This deficient practice could affect all occupants within the facility.

Findings include:

Observation and interview on 09/29/20 at 3:46 p.m., revealed the facility failed to maintain the fire alarm system in the Basement by the furnaces. This area contained a smoke detector that was not securely fastened to the ceiling and was hanging by wires.

The Facilities Director did not verify this finding as he was not present during the inspection.

Based on record review and interview, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including patients, staff, and visitors. The facility had a capacity of 49 and a census of 22 patients at the time of the survey.

Findings include:

1. Record review and interview on 09/28/20 at 10:55 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Interim Life Safety Management Policy, revealed the intervals at which security personnel were directed to perform fire watches, but did not include that the fire watch was to be performed by a dedicated staff member and that the fire watch is continuous and that all portions of the facility will be checked at least once every 30 minutes.

2. Record review and interview on 09/28/20 at 10:55 a.m. revealed the fire watch policy failed to contact the following entities at the beginning and the end of the fire watch: State Fire Marshal's Office, the local fire department, and the Iowa Department of Inspections and Appeals (DIA). The policy did not include the phone numbers to these entities.

3. Record review and interview on 09/28/20 at 10:55 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Fire Alarm System Shutdown policy, revealed the policy did not state that the employee assigned to the fire watch shall be trained in fire prevention, as required.

This policy was last revised on 10/01/14. The Facilities Director verified the documentation at the time of the survey process.

Based on record review and interview, the facility failed to conduct the required biennial sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 14.4.5.3.2. This deficient practice affects all occupants as this lack of testing would not ensure the sensitivity of the detectors was within the manufacturer's specification.

Findings include:

Record review on 09/29/20 at 3:39 p.m., revealed the fire alarm inspection paperwork at the panel was missing a sensitivity test available for review.

The Facilities Director did not verify this as he was not on site during the inspection.

Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including patients, staff, and visitors. The facility had a capacity of 49 and a census of 12 patients at the time of the survey.

Findings include:

Record review on 09/28/20 at 10:07 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was incomplete in that it did not address and was missing the following information:

1. Assigning an impairment coordinator.

2. Tagging an impaired system that has been removed from service at each fire department connection and the system control valve indicating which system, or part thereof, has been removed from service.

3. All preplanned impairments shall be authorized by the impairment coordinator, who shall verify the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(6) The insurance carrier has been notified and its phone number.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented.
(9) All necessary tools and materials have been assembled on the impairment site.

4. Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

5. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The insurance carrier, alarm company, and Iowa DIA have been advised that protection is restored.
(5) The impairment tag has been removed.

Facilities Director verified the documentation at the time of the survey process.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for one of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 49 and a census of 22 patients at the time of survey.

Findings include:

Record review and interview on 09/28/20 at 11:30 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct a fire drill during the second shift and third shift for the fourth quarter of 2019.
Facilities Director verified the documentation during the survey process.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all residents, staff, and visitors. The facility had a capacity of 44 and a census of 22 patients at the time of the survey.

Findings include:

Record review on 09/29/20 at 12:40 p.m., revealed the facility was unable to provide the minimum required documentation of non-hospital-grade receptacle testing or documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles.

Facilities Director confirmed this finding at the time of the survey.

Based on record review and interview, the facility failed to maintain the generator set and test essential electrical system (EES) circuitry as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.4.3.1, 6.5.4.1.1.1, and 6.4.4.1.2, by not completing annual inspection and exercising of main and feeder circuit breakers. The deficient practice affects all of the smoke compartments throughout the building and all occupants. The facility had a capacity of 49 and a census of 22 patients at the time of the survey.

Findings include:

Record review on 09/29/20 at 12:05 p.m., revealed the facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers. Interview of the Facilities Director revealed that he didn't believe that this was being conducted and will need to contact the generator company. He was unclear on the exact requirements for the inspection and exercising.

The Facilities Director acknowledged this finding during the survey process.