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

Findings:

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


On 07/10/19 at 2:30 pm, the surveyor asked Staff D if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff D stated the facility was in the process of developing the policy.

Based on observation and interview the facility failed to ensure egress doors could be opened with one action as required.

Findings:

On 07/10/19 at 3:11 pm the surveyor observed deadbolt locks on two physical therapy room corridor doors and one on the dining room corridor door which would take two actions to gain access to the egress pathway.

On 07/10/19 at 3:11 pm the surveyor asked staff C why there were deadbolts on the corridor doors which would take two actions to open. Staff C stated the deadbolts had always been there as of the time they took over the hospital in July 2017 and they did not really know why the deadbolts were installed. Staff C stated they would have them changed with a lock that will only take one action to open the door to be in compliance.

Based on record review and interview the facility failed to ensure the facility fire alarm system was inspected and tested annually with records of inspection/testing provided when requested as required.

Findings:

Record review of facility fire alarm system inspection reports showed the last fire alarm system (FAS) annual inspection was completed on 04/13/18 and there was no FAS annual for 2019 which was due April/2019.

On 07/10/19 at 1:08 pm the surveyor asked Staff C for the annual FAS inspections for 2017, 2018, and 2019. Staff C stated they did not have the 2017 as they had just taken over the facility but will look for the 2018, and 2019. Staff C came back later and only provided a American Fire Protection FAS annual inspection dated 04/13/18.

Based on observation, and interview the facility failed to ensure the sprinkler system piping was free of any attached items as required.

Findings:

On 07/10/19 at 3:40 pm the facility sprinkler system piping in the dry good storage of the kitchen was observed to have telephone cabling zipped tied to the sprinkler piping.

On 07/10/19 at 3:45 pm the surveyor asked Staff C what is the cabling that is zipped tied to the sprinkler piping located in the dry good storage in the kitchen. Staff C stated the cabling is telephone cabling. The surveyor stated that code prohibits anything from touching or being anchored to sprinkler piping other than the anchors holding only the sprinkler piping itself. Staff C stated they will have it taken care of.

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 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.

On 07/10/19 at 3:54 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 2017 and 2018 were not completed and the documentation did not exist.

On 07/10/18 at 2:33 pm the surveyor asked Staff C for the annual fire rated door assembly inspections. Staff C stated the inspection was not completed for 2017, 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 and do not exist.

On 07/10/19 at 2:35 pm the surveyor asked staff C for the EES and Medical Gas building system risk assessments. Staff C stated they were not aware of the requirement but would ensure they will be completed.

Based on record review and interview the facility failed to ensure the facility medical gas systems were inspected/maintained annually as required.

Findings:

Record review showed the facility did not complete annual medical gas inspection testing for 2018 or 2019. A Stacy Systems observation report dated 10-9-18 indicated an "observation only" of the medical gas system was done but no testing was completed.

On 07/10/19 at 3:56 pm the medical gas systems annual inspections/testing were requested for 2018 and 2019 and were not provided as they do not exist.

On 07/10/19 at 3:56 pm the surveyor asked staff C why the medical gas inspection/testing were not completed. Staff C stated that they thought it had been done but will get it scheduled.

Based on record review and interview the facility failed to ensure having a letter of reliability from its natural gas vendor to demonstrate the fuel source is reliable and meets the requirements for an on-site backup emergency generator as required.

Findings:

Record review showed the facility did not have a letter of reliability from its natural gas vendor for its emergency generator.

On 7/10/19 at 1:23 pm the surveyor asked staff C if their emergency generator was diesel or natural gas. Staff C stated it was gas. The surveyor stated they needed to have a letter of reliability from their gas vendor.