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Based on document review and interview, the hospital failed to develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach that was based on and included a documented facility-based and community-based risk assessment and emergency plans to address the facility- and community-based disasters as outlined in Appendix Z of the Centers for Medicare and Medicaid Services (CMS).

Findings include:

1) On 07/29/2020, document review revealed the hospital's emergency preparedness plan titled "Emergency Management & Operations Plan," failed to address the following:

a) Man-made disasters
b) Natural disasters
c) Care-related emergencies
d) Equipment and utility failures
e) Interruptions in communications, including cyber attacks
f) Loss of all or portion of the hospital
g) Interruption to the normal supply of essential resources, such as water, food, fuel, medications, and medical supplies.

The above documents were requested, but were not received prior to completion of the survey.

The above deficiencies were acknowledged by the Chief Executive Officer and Plant Operations Director during the exit interview.

Based on document review and interview, the hospital failed to develop and maintain an emergency preparedness plan that: 1) was based on, and included documented, facility-based and community-based risk assessments, utilizing an all-hazards approach, and 2) included strategies that addressed emergency events identified by the risk assessments.

Findings include:

1) On 07/29/2020, document review revealed the hospital's emergency preparedness plan was not based on, and did not include, documented facility-based and community-based risk assessments. During an interview, the Director of Plant Operations indicated that a facility-based risk assessment was completed by the Risk Manager, but local and state emergency preparedness officials were not contacted to obtain or complete a community-based risk assessment.

On 07/29/2020 at approximately 1:20 PM, the hospital's Risk Manager and Director of Plant Operations provided a facility-based risk assessment, however, the risk assessment was related to maintenance and environment of care issues and did not pertain to the hospital's emergency preparedness plan.

2) A review of hospital's emergency preparedness plan, did not include strategies that addressed any emergency events with the exception of a plan that was included to address "Pandemic Influenza." During an interview on 07/29/2020 at approximately 1:25 PM, the hospital's Risk Manager indicated the facility maintained their emergency plans on the computer system and would print copies for the surveyor's review. No documentation was provided prior to completion of the survey.

The above deficiencies were acknowledged by the Chief Executive Officer and Maintenance Director during the exit interview.

Based on document review and interview, the hospital failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Findings include:

On 07/29/2020, document review revealed the hospital did not include a process for cooperating and collaborating with emergency preparedness officials efforts to maintain an integrated response during disasters or emergency situations.

During an interview on 7/29/2020 at 11:20 AM, the Director of Plant Operations indicated the facility attempted to communicate with local and state emergency preparedness officials on multiple occasions without response. The facility did not have a written policy or process for cooperation and collaboration with emergency preparedness official.

The Chief Executive Officer and Director of Plant Operations acknowledged this deficiency during the exit interview.

Based on document review, the hospital failed to develop and implement emergency policies and procedures to address the provision of subsistence needs for staff, whether they evacuate or shelter in place.

Findings include:

On 07/29/2020, a review of the hospital's emergency policies revealed the facility did not have a policy to address the provision of subsistence needs for staff. The hospital's emergency policy included procedures that addressed the provisions of food, water, medical, and pharmaceutical supplies for patients, but did not address staff or volunteers that may be required to evacuate or shelter-in-place.

The Chief Executive Officer and Director of Plant Operations acknowledged this deficiency during the exit interview.

Based on document review, the hospital failed to develop and implement emergency policies and procedures to track the location of on-duty staff and sheltered patients in the facility's care during an emergency.

Findings include:

On 07/29/2020, a review of the facility's emergency policies revealed the facility did not have a policy to track the location of on-duty and sheltered patient's in the facility's care during an emergency. A copy of the facility's policy was requested, but was not provided prior to completion of the survey.

The Chief Executive Officer and Director of Plant Operations acknowledged this deficiency during the exit interview.

Based on document review and interview, the hospital failed to develop and implement emergency preparedness policies and procedures for the safe evacuation from the facility that addressed all items outlined in 42 CFR 482.15(b)(2).

Findings include:

On 07/29/2020, a review of the facility's policy and procedure for the safe evacuation from the hospital revealed the following deficiencies:

1) The hospital's policy for safe evacuation did not address staff responsibilities during an event or disaster that requires evacuation from the hospital. The hospital's emergency preparedness policy contained a list of staff responsibilities for personnel assigned the to Emergency Operations Center, but did not address staff responsibilities in the event an evacuation of the facility was required.

2) The hospital's policy for the safe evacuation from the hospital stated "Transportation will be managed by local and area ambulance, police, or fire." The policy did not contain contact information or indicate a means to obtain transportation from local and area emergency services nor were methods to obtain non-emergent transportation services included in the hospital's safe evacuation policy.

3) The hospital's policy for safe evacuation from the facility did not identify an alternate means of communication with external sources of assistance. The hospital's communication plan refers to the hospital's Emergency Operations Center policy that stated "A Satellite phone should be located here." During an interview on 07/29/2020 at 2:20 PM, the Director of Plant Operations and Chief Executive Officer indicated the hospital did not have a satellite phone.

All deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on document review, the facility failed to develop and implement emergency preparedness policies for sheltering in place.

Findings include:

On 7/29/2020, a review of the hospital's emergency preparedness plan revealed the hospital did not have a policy in place to address a means to shelter in place for patients, staff, and volunteers. A policy and procedure that addressed a means to shelter-in-place for patients, staff, and volunteers was not provided prior to completion of the survey.

The Chief Executive Officer and Director of Plant Operations acknowledged this deficiency during the exit interview.

Based on document review and interview, the hospital failed to develop and implement emergency preparedness policies that addressed the use of volunteers in an emergency or other emergency staffing strategies that included: 1) a process for the integration of State or Federal designated health care professionals to address surge needs during an emergency, 2) any necessary privileging and credentialing process for volunteering health care providers; or 3) the use of non-medical volunteers.

Findings include:

On 07/29/2020, a review of the hospital's policy and procedure for the use of volunteers revealed the following deficiencies:

1) The use of volunteer policy that was included in the facility's "Emergency Management & Operations Plan, 2020" was not facility specific and included information for integrating health care professionals in Alaska. Additionally, the hospital's use of volunteer policy was incomplete as demonstrated by the following statement included in the facility's policy: "The volunteer will be required to wear a NEED TO COME UP WITH SOME TYPE OF ID CARD AND INSERT THAT LANGUAGE HERE."

2) The use of volunteer policy did not contain any information concerning the privileging and credentialing process for the location of the facility. The volunteer policy was not facility specific and included the credentialing process for health care professionals in the State of Alaska; cross-referencing the Alaska State Medical Association Database for verification; and the requirement to hold a current license to in the State of Alaska to perform volunteer duties at the hospital.

3) The use of volunteer policy did not address the use of non-medical volunteers.

The above deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on document review and interview, the hospital failed to develop and implement emergency preparedness policies and procedures that included the development of arrangements with other hospitals, other providers to receive patients, and transportation services in the event of limitations or cessation of operations to maintain the continuity of services to the hospital's patients.

Findings include:

On 07/29/2020, document review revealed the hospital's emergency preparedness plan did not include a policy and procedure for the development of arrangements with other hospitals, other service providers, and transportation services required in the event of limitation or cessation of services provided. The hospital's emergency preparedness plan listed one local hospital, however it did not include a written, memorandum of agreement or a contractual agreement between the two facilities. In addition, the hospital's emergency plan did not include arrangements made with other service providers or those made with transportation services.

A copy of the written agreements between the hospital with other hospitals, other service providers, and transportation services were requested, but not provided prior to completion of the survey.

The Chief Executive Officer and Director of Plant Operations acknowledged the above deficiencies during the exit interview.

Based on document review and interview, the hospital failed to develop and implement emergency preparedness policies and procedures that addressed the role of the hospital 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 as identified by emergency management officials.

Findings include:

On 07/29/2020, a review of the hospital's emergency preparedness plan revealed the facility failed to develop and implement a policy to address the role of the hospital under a waiver declared by the Secretary in accordance with section 1135 of the Act. A copy of the facility's policy and procedure was requested, but was not provided prior to the completion of the survey.

This deficiency was acknowledged by the Chief Operations Officer and Director of Plant Operations during the exit interview.

Based on document review and interview, the hospital failed to develop and maintain an emergency preparedness communication plan that included the names and contact information for entities providing services under arrangement; patient physicians; other facility's; and volunteers.

Findings include

On 07/27/2020, document review revealed the hospital's communication plan included the names and contact information for staff members, but did not include contact information for entities providing services under arrangements; patients' physicians; other facilities; or volunteers. A copy of this information was requested, but was not provided prior to survey completion.

The above deficiency was acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on document review and interview, the hospital failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance.

Findings include

On 07/27/2020, document review revealed the hospital's communication plan did not include the contact information for Federal, State, tribal, regional, and local emergency preparedness officials and other sources of assistance. The hospital's policy indicated the facility will use "land lines capable of long distance calls," and cellular phones to contact the "community response network." The hospital's communication plan did not include contact information for emergency preparedness staff or other sources of assistance.

The above deficiency was acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on document review and interview, the hospital failed to develop and maintain an emergency preparedness communication plan that: 1) included a primary and alternative means of communicating with Federal, State, tribal, regional, or local emergency management agencies; 2) outlined expected challenges to the communication system; and 3) ensured the selected alternative means of communication was compatible with the communication systems of other facilities, agencies, and state and local officials.

Findings include:

On 07/29/2020, a review of the hospital's emergency communication plan revealed the following:

1) The hospital failed to include an alternative means to communicate with the Federal, State, tribal, regional, or local emergency management agencies. The facility's plan addressed utilizing a "satellite phone" at the hospital's Emergency Operations Center, the use of telephones, computer email, pagers, and hand held radios for communicating with "the community response network." During an interview on 07/29/2020 at 11:40 AM, the Chief Executive Officer indicated that the facility did not own a satellite phone or pagers and the facility's hand-held radios did not communicate external to the facility.

2) The hospital failed to develop a communication plan that outlined expected challenges to the communication system. Specifically, the hospital's communication plan did not take into consideration a loss of land-line phones, cellular networks, or loss of electricity. The hospital's policy listed telephones as the primary means of communications and facility or personally owned cellular phones as an alternate means to communicate during a disaster or emergency event. The facility listed hand-held radios (internal only), computer email, and facsimile as alternate communication methods. The hospital's policy did not address loss in telephone, cellular, or Internet services.

Additionally, the hospital's "When to Use Each Communication System" contained the following statement, "NOTE: Cellular phones do not have reception in many parts of the acute hospital."

3) The hospital failed to ensure that selected alternative means of communications were compatible with the communication systems of other facilities, agencies, and state and local officials it plans to communicate with. During an interview on 7/29/2020 at 11:40 AM, the Director of Plant Operations indicated that the hospital utilized land-line telephones, cellular phones, and radios for communicating with external organizations. The Director of Plant Operations indicated the facility had not verified that its communication systems were compatible with those in other facilities and emergency response agencies.

The deficiencies listed above were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on document review and interview, the hospital failed to develop an emergency preparedness communication plan that included a means of providing information about the hospital's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction (AHJ), the Incident Command Center (ICC), or designee.

Findings include:

On 07/29/2020, document review revealed the hospital's emergency preparedness plan did not include a policy or procedure that included a means of providing information about the hospital's occupancy, needs, and ability to provide assistance, to the AHJ, ICC, or designee. A copy of this policy was requested, but was not provided prior to completion of the survey.

The above deficiency was acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on document review and interview, the hospital failed to 1) participate in a full-scale exercise that was community-based, conduct a facility-based functional exercise, or experience a natural or man-made emergency that required activation of the emergency plan; and 2) conduct a second full-scale exercise that was community based or individual, facility-based functional exercise, a mock disaster drill, or a tabletop exercise.

Findings include:

1) On 07/29/2020, document review revealed the hospital failed to participate in a full-scale exercise that was community-based, a facility-based functional exercise, or experienced a natural or man-made emergency that required activation of the emergency plan annually. On 07/29/2020 at 11:40 am, the Director of Plant Operations provided two documents titled "Disaster Event Evaluation" that indicated the hospital experienced an "Emergency Loss of Power," on 09/12/2019 between 3:30 AM and 1:30 PM and an "Emergency Loss of Water to Dietary" on 12/21/19 between 2:00 PM and 8:00 PM. A review of the documentation reveled the facility's "Loss of Power" was a facility-based, announced drill and did not require activation of the emergency plan. A review of the documentation reveled the facility's "Emergency Loss of Water to Dietary" did not require activation of the emergency plan.

On 7/29/2020 at 2:20 pm, during an interview the Director of Plant Operations indicated that both disaster events/drills did not involve activation of the facility's emergency plan and did not involve any agencies external to the hospital. Additionally, the Director of Plant Operations indicated that he had not contacted Federal, State, or local emergency officials to inquire about participating in a community-based, full-scale exercise.

2) Document review revealed the hospital did not conduct an additional exercise at least annually, that included a second full-scale community-based or individual, facility based functional exercise; a mock disaster drill; or a table top exercise or workshop that was led by a facilitator, included group discussions using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. The Director of Plant Operations indicated the facility performs fire drills as required, but has not participated in any full-scale drills.

The above deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on document review and interview, the hospital failed to implement emergency and standby power systems based on the emergency plan that included a plan for how it will keep emergency power systems operational during an emergency.

Findings include:

On 7/29/2020, document review revealed the hospital's emergency preparedness plan did not include a policy or procedure that addressed a plan to keep emergency power systems operational during the emergency. During an interview, the Director of Plant operations indicated that the facility relies on a third-party to keep the facility's emergency power system operational throughout an emergency. A copy of the hospital's contractual agreement for emergency maintenance, repairs, and fuel replenishment was requested from the Director of Plant Operations and Chief Executive Officer on 07/29/2020 at 2:20 PM, but were not provided prior to completion of the survey.

This deficiency was acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

National Fire Protection Association (NFPA) 101, Life Safety Code (2012 Edition).

9.6.3.2.3* Smoke detectors located at doors for the exclusive operation of automatic door release shall not be required to activate the building evacuation alarm, provided that the power supply and installation wiring to the detectors are monitored by the building fire alarm system, and the activation of the detectors initiates a supervisory signal at a constantly attended location.

Based on observation and interview, the facility failed to ensure that 1) doors located in a smoke or fire barrier were activated by manual and/or automatic initiating devices; and 2) smoke detectors located at doors for the exclusive operation of automatic door release activated the building's fire alarm system or initiated a supervisory signal at a constantly attended location.

Findings include:

1) On 7/31/2020 at 10:50 AM, the facility's Director of Plant Operations indicated closure of the rolling steel fire door located in Building A between the south and west nursing stations was initiated by manual pull station and smoke detectors located within the smoke compartment. The Director of Plant Operations was asked to initiate closure of the rolling steel fire door by utilizing a manual pull station. At 10:55 AM, the Director of Plant Operations activated the manual pull station located at the west nursing station, however the door did not close upon initiation of the manual pull station. The Director of Plant Operation reset and reactivated the alarm several times, but the manual pull station failed to close the rolling steel fire door.

On 07/31/2020 at 11:30 AM, the Director of Plant Operations indicated that a call was placed to the facility's contracted vendor. Per the Director of Plant Operations, the vendor reported closure of the door was initiated by smoke detection. A second test of the facility's rolling steel fire door was performed using smoke to initiate closure of the door. The door failed to close when initiated by the smoke detector located adjacent to the door. The facility was unable to provide evidentiary documentation or demonstrate the rolling steel fire door was connected to the fire alarm system.

2) On 07/31/2020 at 8:15 PM, documentation of the vendor's repairs to the rolling steel fire door was received and the vendor's test of the fire door was observed. The vendor's test of the fire alarm system revealed that the rolling steel fire door was activated by smoke detection, however the building's fire alarm was not initiated. Evidence that activation of the fire door initiated a supervisor signal at a constantly attended location was requested, but was not available at that time.

On 08/04/2020 at 9:50 AM, the hospital provided the vendor's report of the repairs and retest that indicated a supervisory signal was sent to the annunciator located at the Building A, west nursing station upon activation of the rolling steel fire door. Upon review of the documentation, the facility was allowed to secure the fire watch at that time.

All observations were made in the presence of the Director of Plant Operations. All deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations.

National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (2010 Edition)

17.14.5 Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible.

Based on observation, the hospital failed to ensure that all manual fire alarm boxes were installed so that they were conspicuous, unobstructed, and accessible.

Findings include:

1) During the facility tours on 07/29/2020 through 07/31/2020, observation revealed that manual alarm boxes were inconspicuous, obstructed, and/or inaccessible in the following locations:

a) Unit C North, Nursing Station - The manual fire alarm box was obstructed and made inaccessible by a record cart.
b) Unit C North, Noisy Activity Room - The manual fire alarm box was obstructed by a chair.
c) Unit C South, Nursing Station - The manual fire alarm box was obstructed by a trash can.
d) Unit C South, Noisy Activity Room - The manual fire alarm box was obstructed by a chair.
e) Geriatric Unit, Nursing Station - The manual fire alarm box was obstructed and made inaccessible by a patient scale and a plastic file cabinet.
f) Psychiatric Intensive Care Unit - The manual fire alarm box was obstructed by the unit's paper shredding bin.
g) Unit A West, Nursing Station - The manual fire alarm box was obstructed and made inaccessible by a crash cart.
h) Unit A North, Nursing Station - The manual fire alarm box was obstructed by a vital signs machine
i) Unit A South, Nursing Station - The manual fire alarm box was obstructed by a television.
j) Kitchen - The manual fire alarm box located at the service entrance was obstructed and made inaccessible by a food cart.
k) Kitchen - The manual activation device for the kitchen's ANSUL system was obstructed and made inaccessible by 3 food carts.

All observations were made in the presence of the Director of Plant Operations. All deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (2010 Edition).

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

14.4.5.1 Devices or equipment that are inaccessible for safety considerations (e.g. continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be tested during scheduled shutdowns if approved by the authority having jurisdiction. Extended intervals shall not exceed 18 month.

14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.5.3.7.

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

14.4.5.3.3. After the second required calibration test, if sensitivity tests indicated that the device has remained within its listed and marked sensitivity (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

Table 14.4.5 Testing Frequencies
15(h) System smoke detectors - functional test - initial/reaacceptance and annually

14.6.2.4* A record of all inspections, testing, and maintenance shall overprovided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of the person performing inspection, maintenance, tests, or combination there of, and affiliation, business address, and telephone number.
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Function test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification systems
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification to silence fire alarm notification appliances
(15) Test of intelligibility of mass notification system speakers
(16) Other tests as required by the manufacturer
(17) Other tests as required by the authority having jurisdiction.
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g. system owner notified, problem corrected/successfully retested, device abandoned in place).

Based on documentation review and interview, the hospital failed to ensure that 1) annual functional testing was conducted on all installed smoke detectors; 2) smoke detector sensitivity tests were performed on the facility's smoke detectors as required; and 3) the records of all inspections, testing, and maintenance included all information regarding smoke detector testing as required.

Findings include:

1) On 07/29/2020, a review of the facility's maintenance documentation revealed the facility did not have documentation as evidence that annual functionality testing was conducted on all installed smoke detectors. The hospital provided vendor reports as evidence that annual functionality testing was conducted on 36 duct detectors and 6 smoke detectors on 10/14/19. A review of the facility's most recent smoke sensitivity test report indicated the facility had an inventory of 225 detectors on 02/24/2020 and the previous report of sensitivity testing, dated 04/05/2016 indicated the facility had an inventory of 288 detectors. During an interview the Director of Plant Operations was unable to provide documentation or indicate the correct number of smoke detectors installed in the facility.

2) A review of the hospital's smoke detector sensitivity test reports revealed the following deficiencies:

a) The hospital provided documentation that indicated that smoke detector sensitivity testing was performed on 04/05/2016 and 02/20/2020. This indicated that the facility went 3 years, 10 months, and 19 days between smoke detector sensitivity tests and exceeded the 2 year periodicity requirement by 1 year, 10 months and 19 days Per the Director of Plant Operations, smoke detector sensitivity was not conducted during the period between the two sensitivity test reports.

b) The hospital's vendor reports indicated that smoke detector sensitivity testing was performed on 288 detectors on 04/05/2016 and 225 detectors on 02/2/2020. The Director of Plant Operations was unable to provide documentation or indicate the correct number of smoke detectors installed in the facility.

c) The most recent smoke detector sensitivity report, dated 02/20/2020, indicated that sensitivity testing was not performed on nine of the facility's smoke detectors within the past 2 years. Per the vendor report, "No Access" was documented as the reason that sensitivity testing was not performed on the nine smoke detectors. A review of the vendor report from the previous smoke detector sensitivity test revealed that the nine smoke detectors had not been tested since 04/05/2016. The detectors listed below have exceeded the 2 year periodic requirement for smoke sensitivity testing and were overdue for testing by 2 years, 4 months, and 26 days at the time of survey:

1. Room 204 Med Records - visible and accessible in the medical records office above the sliding file cabinets.
2. Room 208 Computer - visible and accessible in the center of the room
3. Room 203 Electric Room - visible and accessible in the center of the room
4. Gym - six smoke detectors were observed as visible and measured at 25 feet 8 inches above the finished floor.

During an interview, the Director of Plant Operations indicated that he was told by his vendor that a scissor-lift was needed to perform sensitivity testing on the smoke detectors located in the Gym. The Director of Plant Operations indicated that he was unaware of the reason that the hospital's vendor did not perform testing on the smoke detectors located in rooms 204, 208, and 203. When asked if a scissor-lift had been obtained and sensitivity testing was scheduled for the smoke detectors that were not tested, the Director of Plant Operations stated "No."

3) Document review revealed the hospital failed to ensure that the vendor report for the smoke detector sensitivity test included all required information. The report of smoke sensitivity testing did included the following items as required:

a) Name of the person that performed the inspection, maintenance, tests or combination thereof
b) Functional test of required sequence of operations
c) Check of all smoke detectors
d) Signatures of the tester and approved authority representative
e) Disposition of problems identified during the test

All observations and measurements were made in the presence of the Director of Plant Operations. The above deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems (2010 Edition).

6.2.9 Stock of Spare Sprinklers.
6.2.9.1* A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.

6.2.9.5 The stock of spare sprinklers shall include all types and ratings installed and shall be
as follows:
(1) For protected facilities having under 300 sprinklers - no fewer than six sprinklers
(2) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers
(3) For protected facilities having over 1000 sprinklers - no fewer than 24 sprinklers

National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (2011 Edition).

5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:
(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5
(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6

Based on observation and interview, the hospital failed to ensure that each sprinkler cabinet contained the correct number and type of sprinklers as reflected on the spare sprinkler list posted on each cabinet.

Findings include:

On 07/30/2020, observation of the facility's spare sprinkler cabinets revealed the following deficiencies:

1) Building B, Riser Room - The list of spare sprinklers located on the external door of the sprinkler cabinet indicated the cabinet contained an inventory of six recessed pendent, six recessed pendent (institutional), one upright, and one side wall sprinklers. Observation revealed the sprinkler cabinet contained two upright and one sidewall sprinkler.

2) Building A, Riser Room - The list of spare sprinklers located on the external door of the sprinkler cabinet indicated the cabinet contained an inventory of six Viking V410 - 155 degree sprinklers, one VK302 - 200 degree sprinkler, and one VK302 - 155 degree sprinkler. Observation revealed the sprinkler cabinet contained five recessed pendent sprinklers.

All observations were made in the presence of the Director of Plant Operations. All deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers (2010 Edition)

6.1.3.3 Visual Obstructions
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

6.1.3.8 Installation Height
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft. (1.53 m) above the floor.

Based on observation, measurement and interview, the hospital failed to ensure that 1) all portable fire extinguishers were not obstructed or obscured from view, and 2) fire extinguishers were installed so that the top of the fire extinguisher is not more than 5 ft. (1.53 m) above the floor.

Findings include:

1) During the facility tours on 07/30/2020 and 07/31/2020, observation revealed that portable fire extinguishers (PFE) were obstructed or were obscured from view in the following locations:

a) Generator Enclosure for buildings A and B - PFE was obstructed by a shop vacuum and two parking signs
b) Building A, West Nursing station - PFE was obstructed by a crash cart
c) Geriatric Unit, Nursing station - PFE was obstructed and obscured from view by a records cart
d) Kitchen - The K-class PFE was obstructed and obscured from view by food carts

2) On 7/30/2020, during the external tour of the facility, observation and measurement revealed the PFE located in the Generator Enclosure for buildings A & B was installed with the top of the PFE at a height of 65 inches above the floor.

All observations and measurements were made in the presence of the Director of Plant Operations. The above deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on observation, the hospital failed to ensure that corridor doors were maintained free from impediments to closure.

Findings include:

On 07/29/2020 through 07/31/2020, during the hospital tours, observation revealed the facility failed to ensure that all corridor doors were free from impediments to closure. The following deficiencies were noted:

1) Resident Room (RR) 104 - The corridor door was held open by a sock wedged between the bottom of the door and the floor)
2) RR 401 - The corridor door was held open by a toilet paper roll that was wedged between the bottom of the door and the floor.
3) RR 402 - The corridor door was held open by a waste basket.
4) RR 404 - The corridor door was held open by a toilet paper roll that was wedged between the bottom of the door and the floor.
5) RR 407 - The corridor door was held open by a wash cloth that was wedged between the bottom of the door and the floor.
6) RR 448 - The corridor door was held open by a wash cloth that was wedged between the bottom of the door and the floor.
7) RR 1009 - The corridor door was held open by a waste basket.
8) RR 1017 - The corridor door was held open by a waste basket.

All observations were made in the presence of, and acknowledged by, the Director of Plant Operations.

Based on observation, the hospital failed to ensure that walls constructed as smoke and fire barriers were sealed at each point of penetration.

Findings include:

On 07/29/2020 through 07/31/2020, observation and measurement revealed unsealed penetrations in the following locations:

1) Building A, Riser Room - A 12 inch x 12 inch vent was installed into the 1-hour firewall in the rear of the riser room. The vent did not appear to have a smoke or fire damper. Per the Director of Plant Operations, he was unaware that the vent had been installed. A review of the facility's damper testing report did not indicate that a damper was tested on this vent.
2) Building C, Oxygen Storage Room - An unsealed penetration with light coming through it was observed in the interstitial space, along the west wall. The penetration was estimated to be 3 inches by 5 inches.
3) Building C, South Hall Entry - An unsealed and unprotected conduit containing computer and network wiring penetrated the 1-hour fire wall located above the double doors used for entry to the South Hall. The conduit measured approximately 5 inches in diameter and was observed with light coming through.
4) Building A, Room 208 - Two unsealed and unprotected conduits used to run computer and network wiring penetrated the floor in the electrical room. located on the second floor. The conduits were each measured at 5 inches in diameter. Each conduit was unprotected and allowed for light penetration and viewing into the room below.

All observations and measurements were made in the presence of the Director of Plant Operations. All deficiencies were acknowledged by the Chief Executive Officer during the exit interview.

Based on observation and measurement, the facility failed to ensure that smoke barrier doors were installed and maintained to resist the passage of smoke.

Findings include:

On 07/30/2019, during the facility tour, the double doors installed between the Geriatric and Psychiatric Intensive Care Units were observed to have a gap that revealed light shining between the doors when closed. The gap was measured to be 1/2 inch and ran the full distance between the doors, from top to bottom.

All observations and measurements were made in the presence of the Director of Plant Operations. All deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (2010 Edition)

19.4* Periodic Inspection and Testing.
19.4.1 Each damper shall be tested and inspected 1 year after installation.
19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
19.4.2 All tests shall be completed in a safe manner by personnel wearing personal protective equipment.
19.4.3 Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required.
19.4.4 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.
19.4.5 The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.
19.4.6 The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations.
19.4.7 The damper shall not be blocked from closure in any way.
19.4.8 The fusible link shall be reinstalled after testing is complete.
19.4.8.1 If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating.
19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered.
19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected.
19.4.10 All documentation shall be maintained and made available for review by the AHJ.
19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives (2010 Edition)
6.5 Periodic Inspection and Testing.
6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences.
6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment.
6.5.4 Full unobstructed access to the damper shall be verified and corrected as required.
6.5.5 Where a fusible link is installed on a combination fire/smoke damper, the fusible link shall be removed for testing the damper for full closure simulating a fire condition per the requirements and frequencies of 19.5.4 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
6.5.6 The test shall be conducted with normal HVAC airflow.
6.5.7 The operation of the damper shall verify that there is no damper interference due to rust or bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.
6.5.8 The damper frame shall not be penetrated by any foreign objects that would affect proper fire damper operations.
6.5.9 The damper shall be verified to not be blocked from closure in any way.
6.5.10 The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature rating, and load rating.
6.5.11 All inspections and testing shall be documented indicating the location of the 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.
6.5.12 All documentation shall be maintained by the property owner and available for review by the authority having jurisdiction.

Based on document review and interview, the facility failed to ensure fire, smoke and combination fire/smoke dampers were tested and inspected every six years as required.

Findings include:

On 07/29/2020, a review of the hospital's maintenance documentation revealed the hospital did not have documentation as evidence that all of the hospital's fire, smoke, and combination dampers were tested and inspected every 6 years. During an interview, the Director of Plant Operations indicated that the hospital had nine smoke dampers installed throughout the facility and the dampers were inspected and tested by a third party vendor in February of 2020, but the documentation from the previous and most recent tests were not available. A copy of the vendor's report of inspection and testing was requested on 07/29/2020 and provided by the Chief Executive Officer on 07/30/2020. Document review revealed the following deficiencies:

a) The vendor's report of inspection and testing indicated that 16 dampers were inspected and tested but did not distinguish if the dampers installed throughout the facility were fire, smoke, and/or combination fire/smoke dampers.
b) The vendor's report of damper testing did not indicate that the facility's dampers were inspected and tested as required. Specifically, the vendor's report contained two columns labeled as "Damper" with "Yes" typed into each column next to each damper that was identified.
c) The vendor's report did not indicate if the damper's fusible links were reinstalled or replaced after completion of testing.
d) The vendor's report did not include the name of the inspector that performed the inspection, deficiencies discovered, or a space that indicated when and how each deficiency was corrected.
e) The facility failed to maintain documentation of the initial, periodic, and most recent report of all fire, smoke, and combination dampers located throughout the facility.

All deficiencies were acknowledged by the Chief Executive Officer and the Director of Plant Operations during the exit interview.

National Fire Protection Association (NFPA) 101, Life Safety Code (2012 Edition)

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency actions required under varied conditions.

19.7.2 Procedure in Case of Fire
19.7.2.1* Protection of patients
19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
19.7.2.1.2 The basic response required of all staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon the staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan.

Based on observation, document review and interview, the facility failed to ensure that 1) fire drills were conducted under varied conditions; and 2) staff were familiar with and could demonstrate the basic response requirements during a fire drill.

Findings include:

1) On 7/29/2020, document review revealed the facility failed to conduct fire drills during the day shift (Identified by the Chief Executive Officer (CEO) as 7:00 AM to 7:00 PM) and the night shift (Identified by the CEO as 7:00 PM and 7:00 AM) under varied conditions. Specifically, the facility conducted 4 of 6 fire drills on the day shift between 1:50 PM and 2:30 PM, and 4 of 5 drills conducted during the night shift shift between 3:10 AM and 4:30 AM.

2) On 07/31/2020 at 10:40 AM, the hospital conducted an unannounced fire drill in the laundry room that was located directly in front of Nursing Station A. Observation revealed the following deficiencies:

a) At 10:40 AM, the Director of Plant Operations commenced the fire drill by informing five staff members that were located at the nursing station that there was a fire in the laundry room. This did not illicit a response from any staff members that were working in the vicinity of the nursing station or the laundry room.
b) At 10:42 AM, the Director of Plant Operations informed a housekeeping assistant that there was a fire in the laundry room. The housekeeping assistant left the smoke compartment. Prior to leaving the smoke compartment, the housekeeping assistant failed to ensure that no patients were directly involved with the fire emergency; transmit an appropriate fire alarm signal to warn other building occupants and to summon other staff; or isolate the fire by closing the doors on the laundry.

During an interview conducted on 07/31/2020 at 10:48 AM, the housekeeping assistant indicated that she left the area to alert other staff using the facility's overhead paging system. Per the housekeeping assistant the facility's overhead paging system could be activated by phone at the nursing station, but all phones were being utilized by other staff members at the time.

c) Between 10:43 AM and 10:45 AM, additional verbal announcements were made to alert the five staff members that were located at the nursing station of the fire in the laundry room. No staff response or acknowledgement of the announcement was observed.
d) The fire drill was secured at 10:46 AM due to the lack of staff response.

All observations were made in the presence of the Director of Plant Operations. All deficiencies were acknowledged by the CEO and Director of Plant operations during the exit interview.

Based on document review, observation, and interview, the hospital failed to 1) adopt smoking regulations as required; 2) adhere to the hospital's smoking policy; 3) provide noncombustible ashtrays in the locations that were identified as staff smoking areas; and 4) ensure that metal containers with self-closing cover devices into which ashtrays can be emptied, readily available to all areas where smoking was permitted.

Findings include:

1) On 07/29/2020, a review of the hospital's smoking policy issued on 04/01/2008 and last reviewed on 01/17/2020 revealed the hospital's smoking policy did not include the following provision:

a) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous locations, and such areas shall be posted signs that read NO SMOKING or shall be posted with the international symbol for smoking.

2) On 07/29/2020 and 07/30/2020, document review and observation revealed the facility failed to adhere to its smoking regulation. The facility's smoking policy stated "Employees, physicians, and consultants are prohibited from using tobacco substances in any area other than the designated outside area located behind the dumpster wall adjacent to the South side of the building."

Failure of the hospital to adhere to its established smoking regulation is evidenced by:

a) On 07/29/2020 at 7:40 AM, during the external tour of the facility, the Director of Plant Operations indicated the designated employee smoking area was located at the southwest corner of Building "B." This area was not listed as a designated staff smoking area in the hospital's smoking regulations.
b) On 07/30/2020 at 10:40 AM, a staff member was observed smoking a cigarette while standing approximately 5 feet from the northwest entrance to the building. During an interview, the staff member pointed to cigarette butts discarded in the landscaped rock area directly adjacent to her. The staff member stated "I'm in the shade because it is hot and nobody has ever told me not to smoke here." This area was not listed as a designated staff smoking area in the hospital's smoking regulations.

3) On 07/29/2020, during the external tour of the hospital, observation revealed the hospital did not provide ashtrays of noncombustible material and safe design in the employee smoking area identified by the hospital's smoking regulation as "behind the dumpster wall adjacent to the south side of the building" or on the southwest corner of Building "B" as identified by the Director of Plant Operations. During an interview, the Director of Plant Operations indicated the facility has placed noncombustible ashtrays in all of the patient smoking areas, but was unable to place noncombustible ashtrays in the employee smoking areas due to theft and vandalism.

4) On 07/30/2020 and 07/31/2020, during the hospital tour, observation revealed the facility failed to provide a metal container with a self-closing cover device in the facility's smoking areas. During an interview, the Director of Plant Operations indicated that the facility did not have self-closing metal containers for emptying ashtrays.

All observations were made in the presence of the Director of Plant Operations. The above deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on document review and interview, the hospital failed to ensure all fire door assemblies were inspected and tested annually.

Findings include:

1) On 07/29/2020, a review of the hospital's inspection and maintenance documents revealed the hospital did not have documentation as evidence that all fire door assemblies were inspected and tested annually. The hospital's annual report of inspection and testing of all of the facility's fire door assemblies was requested on 07/29/2020 at 9:20 AM. During an interview the Director of Plant Operations indicated the facility did not have documentation as evidence that all fire door assemblies were inspected and tested, because it had not been performed as required.

2) On 07/31/2020, observation revealed that the hospital failed to ensure that the buildings' installed fire shutters were inspected and tested annually. Per the maintenance director, the facility did not have documentation as evidence that the rolling steel door located in building A between the west nursing station and the south nursing station or that the service counter fire door located between the kitchen and the dining room were inspected within the past 12 months. A label was affixed to each door indicated that both doors were inspected and tested by a third-party vendor in March 2019.

The above deficiency was acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

National Fire Protection Association (NFPA) 101, Life Safety Code (2012 Edition).
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies, unless both of the criteria are met:
(1) Such devices are used only in minesweeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F (100 degrees C).

Based on observation and interview, the hospital failed to ensure that portable space-heating devices that were located in nonsleeping staff and employee areas were fitted with heating elements that did not exceed 212 degrees Fahrenheit (100 degrees Celsius).

Findings include:

During the facility tours on 07/30/2020 through 07/31/2020, observation revealed that staff were utilizing portable space-heating in staff and employee areas. Portable space-heating devices observed without a label or documentation to verify the device's heating element did not exceed 212 degrees Fahrenheit (100 degrees Celsius) in the following locations::

Room 467 - Consultation room
Room 475 - Physician's office
Room 1050 - Social Work office

During an interview on 07/30/2020 at 8:35 AM, the Director of Plant Operations indicated that staff will bring portable space-heating devices without the hospital's knowledge. The Director of Plant Operations indicated that he had not verified any labels, manuals, or specification sheets to determine if the heating devices contain elements that did not exceed 212 degrees Fahrenheit.

All observations were made in the presence of the Director of Plant Operations. All deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on observation and interview, the facility failed to ensure that 1) Non-hospital grade electrical receptacles were tested at intervals not exceeding 12 months; and 2) hospital-grade receptacles were tested after initial installation, replacement, or servicing and at intervals defined by documented performance data.

Findings include:

1) On 07/29/2020, document review revealed the hospital did not perform annual testing on all non-hospital grade electrical receptacles located throughout the facility.

2) On 7/29/2020, document review revealed the hospital did not perform testing on hospital grade receptacles upon installation, replacement or servicing nor did the hospital obtain performance data to define the intervals for testing of the facility's hospital-grade receptacles.

During an interview, the Director of Maintenance indicated that annual testing was not performed on any of the electrical receptacles located throughout the facility due to staffing shortfalls. The Director of Plant Operations also indicated that he was unaware of the requirements for testing of hospital-grade receptacles.

The deficiencies listed above were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

National Fire Prevention Association (NFPA) 110, Standard for Emergency and Standby Power Systems (2010 Edition)

7.11 Protection.
7.11.1 The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS.
Parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room.

8.2* Manuals, Special Tools, and Spare Parts.
8.2.1 At least two sets of instruction manuals for all major components of the EPSS shall be supplied by the manufacturer(s) of the EPSS and shall contain the following:
(1) A detailed explanation of the operation of the system
(2) Instructions for routine maintenance
(3) Detailed instructions for repair of the EPS and other major components of the EPSS
(4) An illustrated parts list and part numbers
(5) Illustrated and schematic drawings of electrical wiring systems, including operating and safety devices, control panels, instrumentation, and annunciators

8.4 Operational Inspection and Testing
8.4.1* EPSSs, including all appurtenant components shall be inspected weekly and exercised under load at least monthly.
8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Based on observation, document review, and interview, the hospital failed to: 1) ensure that all EPSSs (Emergency Power Supply Systems) were exercised under load at least monthly; 2) maintain at least two sets of instruction manuals for each EPSS; and 3) ensure EPSSs enclosures were not used for other purposes that were not directly related to the EPSS.

Findings include

1) On 07/29/2020, a review of the monthly generator test logs revealed that the hospital did not exercise all three generators, under load, at least monthly during the past 12 months. The monthly generator test logs did not contain information on the load under which each generator was exercised. During an interview, the Director of Plant Operations indicated that each generator was run for 30 minutes each month, but was unable to provide documentation as evidence that each generator was exercised for 30 minutes under operating temperature conditions and at not less than 30 percent of each generator's nameplate kW rating .

2) On 7/30/2020, during the external tour of the facility, observation reveled that the hospital did not maintain a set of instruction manuals for each generator. During an interview, the Director of Plant Operations indicated that a manual for each generator was but were not received prior to completion of the survey.

3) On 07/30/2020, observation revealed the generator enclosure that houses the 60 kW and 100 kW generators used to service buildings A and B was used as storage for a shop vacuum, supply cart, 2 parking signs, parking cones, a power washer, a wheel-barrow, and cardboard and wood storage. Additionally, the enclosure housed a yellow flammable materials locker that contained various flammable materials such as: 2 compressed helium tanks; a gas cylinder without labeling that identifies its contents; a small yellow propane tank; latex paint; solvents; and a mixture of aerosol cans. The locker door was left open and was approximately 6 feet from the 100 kW generator. During an interview the Director of Plant Operations indicated the generator enclosure was used as storage due to a lack of storage area within the hospital.

All observations were made in the presence of the Director of Plant Operations. The above deficiencies were acknowledged by the Chief Executive Officer and Director of Plant Operations during the exit interview.

Based on observation, the hospital failed to ensure that a precautionary sign was placed on the door of the oxygen storage and included the minimum requirements as directed.

Findings include:

On 07/30/2020, observation revealed the facility failed to place a precautionary sign on the door of the oxygen storage room that stated "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Two placards were observed on the oxygen storage room door, one yellow placard that read "Oxygen" and a white sign that stated "Oxygen Stored."

All observations were made in the presence of the Director of Plant Operations.