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Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include 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 identified by emergency management officials in accordance with 42 CFR 482.15(b)(8). This deficient practice could affect all occupants.

Findings include:

Based on review of "Emergency Operations Plan" documentation with the Director of Plant Operations (DPO) during record review from 9:45 a.m. to 2:45 p.m. on 11/14/18, the facility's Emergency Preparedness Program documentation did not expressly state the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act. Based on interview at the time of record review, the DPO stated the facility had statements in the documentation describing what an 1135 waiver is and how to apply for one but agreed the facility's Emergency Preparedness Program documentation did not expressly state the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act.

Based on record review, observation and interview; the facility failed to ensure 6 of 6 hospital corridors were provided with a complete interior finish with a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. LSC 10.2.3.4 states products required to be tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale.
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Director of Plant Operations (DPO) from 9:45 a.m. to 2:45 p.m. on 11/14/18, interior finish flame spread rating documentation was not available for review. Based on observations with the DPO during a tour of the facility from 2:45 p.m. to 4:00 p.m. on 11/14/18, paneling was installed on the walls in all corridors of the hospital, excluding the main entrance and office areas, from the floor to the ceiling. Based on interview at the time of the observations, the DPO stated the paneling is called FRP board, it is not treated with flame retardant materials by hospital staff, he was not aware of the flame spread for the interior finish and agreed flame spread rating documentation for the FRP board was not available for review at the time of the survey.

Based on observation and interview, the facility failed to ensure 1 of over 100 sprinklers in the facility were installed in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, at 9.2.3.5.1 states the cumulative horizontal length of an unsupported armover to a sprinkler, sprinkler drop, or sprig-up shall not exceed 24 inches for steel pipe or 12 inches for copper tube. This deficient practice could affect over 2 patients, staff and visitors in the vicinity of the main entrance lobby.

Findings include:

Based on observations with the Director of Plant Operations (DPO) during a tour of the facility from 2:45 p.m. to 4:00 p.m. on 11/14/18, the four foot horizontal length of steel sprinkler pipe which is an armover to a sprinkler was unsupported near the ceiling in the foyer for the main entrance lobby. Based on interview at the time of the observations, the DPO agreed the four foot horizontal length of steel sprinkler pipe armover to a sprinkler was unsupported in the aforementioned area.

Based on record review and interview, the facility failed to provide complete documentation for fire drills conducted on the first, second and third shift for 4 of 4 quarters. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of "Fire Drill Report" documentation with the Director of Plant Operations (DPO) during record review from 9:45 a.m. to 2:45 p.m. on 11/14/18, documentation for fire drills conducted on:
a. the first shift on 02/13/18 at 10 a.m., on 05/08/18 at 2:00 p.m., on 09/05/18 at 7:30 a.m. and on 10/19/18 at 12:30 p.m.
b. the second shift on 11/02/17 at 3:13 p.m., 01/05/18 at 8:57 p.m., 04/20/18 at 4:30 p.m. and on 07/18/18 at 6:30 p.m.
c. the third shift on 12/27/17 at 11:16 p.m., on 03/20/18 at 4:00 a.m., 06/14/18 at 1:00 a.m. and on 08/15/18 at 6:00 a.m.
did not include documentation of staff who participated in the drill. In addition, review of fire drill procedures in "Emergency Operations Plan" documentation stated "A sign in sheet shall be used to record the names of all respondents to the drill. This sign in sheet shall be attached to the fire drill critique form." Based on interview at the time of record review, the DPO stated it's too hectic at the time of the drill to obtain and record signatures as staff are usually trying to make sure patients are calm and their needs are being met but agreed fire drill documentation for all shifts for the most recent twelve month period did not include staff who participated in the drill.

Based on observation and interview, the facility failed to ensure of 1 of 1 extension cords including power strips and non-fused multiplug adapters were not used as a substitute for fixed wiring. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. LSC Section 4.5.7 states any building service equipment or safeguard provided for life safety shall be designed, installed and approved in accordance with all applicable NFPA standards. This deficient practice could affect over 2 staff and visitors in the vicinity of the housekeeping storage room near the southwest exit of the facility.

Findings include:

Based on observations with the Director of Plant Operations (DPO) during a tour of the facility from 2:45 p.m. to 4:00 p.m. on 11/14/18, a microwave oven was plugged into a power strip in the housekeeping storage room near the southwest exit of the facility. Based on interview at the time of the observations, the DPO removed the power strip and agreed a power strip was being used as a substitute for fixed wiring at the aforementioned location.