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Based on documentation and staff interview Kindred Hospital of the Palm Beaches failed to comply with Emergency Preparedness Plan , develop and maintain an EP Plan. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The findings included:

During documentation review and staff interview on 05/21/18 at 2:15 PM with the Maintenance Director, it was revealed that the facility's Emergency Preparedness Plan failed to include all essential elements, including but not limited to, an all hazards approach and risk assessment for the facility. The Plan must be evaluated, reviewed and updated annually. The Director of Maintenance acknowledged the absence of the complete Emergency Preparedness Plan.

Based on documentation and staff interview, Kindred Hospital of the Palm Beaches failed to comply with Emergency Preparedness Plan, develop and maintain comprehensive communication plan. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The findings included:

During documentation review and staff interview on 05/21/18 at 4:15 PM with the Director of Maintenance, it was revealed that the facility's Emergency Preparedness Plan failed to include all essential elements, including but not limited to, a comprehensive communication plan and updated vendor list. The Director of Maintenance acknowledged the absence of documentation.

Based on documentation and staff interview Kindred Hospital of the Palm Beaches failed to comply with Emergency Preparedness Plan , develop and maintain comprehensive communication plan. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The findings included:

During documentation review and staff interview on 05/21/18 at 3:15 PM with the Maintenance Director it was revealed that the facility's Emergency Preparedness Plan failed to include all essential elements, including but not limited to, a comprehensive communication plan. Missing documentation includes medical doctor's telephone numbers, staff and volunteer contact information. The Maintenance Director acknowledged the absence of the complete Emergency Preparedness Plan.

Based on observation, staff interview Kindred Hospital of the Palm Beaches failed to comply with NFPA 101 2012 edition, NFPA 96 2011. Cooking equipment used in the process producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard.

The findings Included:

During a tour of the facility on 05/22/18 at 2:50 PM with the Maintenance Director and the Chief Clinical Officer it was observed that a pressure cooker with grease and an electric fry pan were being used in the Doctor's sleeping lounge. This was also acknowledged by the Maintenance Director and the Chief Clinical Officer.

Based on record review and staff interview, Kindred Hospital of the Palm Beaches failed to comply with NFPA 101 and NFPA 72 14.4.3.2 . Duct detector differential annual testing, semi-annual testing NFPA 101 (2012) 19.3.4.1, 9.6, NFPA 72 (2010) edition 10.3.1. The fire alarm system is installed, tested and maintained. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The findings included:

During record review and staff interview on 05/21/18 at 11:00 AM with the Director of Maintenance, the facility failed to produce documentation the the annual differential test on the duct detectors was completed. The Director of Maintenance acknowledged the absence of documentation.

During documentation review and staff interview on 05/21/18 at 11:30 AM with the Director of Maintenance it was revealed that the facility failed to produce documentation that the semi-annual visual inspection was performed. The Director of Maintenance acknowledged that documentation was not provided.

Based on documentation review and staff interview, Kindred Hospital of the Palm Beaches failed to comply with NFPA Life Safety Code 101, NFPA 110 edition 8.3.8., 8.4.9.5.2. Diesel fuel shall be tested under ASTM standards. That all generators and ancillary equipment were tested and certified at an optimal state in accordance with NFPA 101 and NFPA 110 "Standard for Emergency and Standby Power Systems" NFPA 110-8.4.2: Level 1 EPSS shall be exercised once a month under load for a minimum of 30 minutes. Main & Feeder Breaker exercise shall be performed. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The findings included:

During the record review and staff interview on 05/21/18 at 10:35 AM with the Maintenance Director it was revealed that at the time of this survey there was no documentation to show that the Main and Feeder Circuit Breakers were inspected annually as required, including periodic exercise in accordance with manufacture's recommendations.

Interview with the Maintenance Director revealed and acknowledged that the facility did not have a system in place or preventative maintenance program to ensure compliance with NFPA 99 (2012).



NFPA 101 (2012) edition
NFPA 99 (2012) 6.4.4
NFPA 110 (2010) edition 8.4.2

Based on observation and staff interview Kindred Hospital of the Palm Beaches failed to comply with NFPA 99 10.2.3.6. Power cords are not used as a substitute for fixed wiring of a structure. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The findings included:

During a tour of the facility on 05/22/18 at 12:10 PM with the Maintenance Director it was observed that a surge protector in the Doctor Sleeping Lounge was attached to a refrigerator. The Maintenance Director and the Chief Clinical Officer acknowledged and observed the surge protector was being used as a substitute for permanent wiring.

NFPA 99
10.2.3.6

Based on observation and staff interview Kindred Hospital of the Palm Beaches failed to comply Life Safety Code 101 (2012) edition, NFPA 99 (2012) edition 11.3.1. Storing more than 12 "E" oxygen (O2) tanks must be separated from combustibles. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

The findings included:

During a tour of the facility on 05/22/18 at 3:20 PM with the Maintenance Director it was observed that 26 "E" O2 cylinders were stored within five feet of combustibles on the 4th floor in the O2 storage room. The Maintenance Director acknowledged that the O2 tanks were not properly stored.