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Based on record review and interview the facility failed to ensure policy and procedures were established to address the use of volunteers in an emergency.

Findings:

On 07/09/19 at 1:38 pm the surveyor requested documentation to verify the volunteers roles at the facility for disasters. Staff D stated the facility did not have a policy in place, the facility will revise and update their policies and procedures to address the volunteers roles and responsibilities.

Based on record review and interview the facility failed to ensure annual and initial in-service training for staff, and individuals providing services under arrangement, on the emergency preparedness plan for 8 (staff S, staff Z, staff CC staff DD, staff GG staff HH, staff LL, and staff MM. ) of 22 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for new, existing staff, volunteers and individuals providing services under arrangement for the following staff:

Staff S with the date of hire 02/13/17, did not receive initial in-service training for the emergency preparedness plan.

Staff Z with the date of hire 06/01/15 did not receive initial in-service training for the emergency preparedness plan.

Staff CC with the date of hire 05/11/15 did not receive initial in-service training for emergency preparedness plan.

Staff DD with the date of hire 02/27/06 did not receive annual in-service training in 2018 for the emergency preparedness plan.

Staff GG with the date of hire 08/07/11 did not receive annual in-service training 2017-2018 for the emergency preparedness plan.

Staff HH with the date of hire 01/23/16 did not receive initial in-service training for emergency preparedness plan.

Staff LL with the date of hire 10/29/01 did not receive annual in-service training in 2017 for emergency preparedness plan.

Staff MM with the date of hire 06/07/04 did not receive annual in-service training in 2018 for the emergency preparedness plan.

On 07/09/19 at 1:37 pm the surveyor asked Staff D for documentation of training in-service for new, existing staff members, volunteers and individuals providing services under arrangement/contract. Staff D informed surveyor the facilities training system only went back as far as 2006 and she was unable to access and provide training before 2006 because the facility had switched systems and she had no excess to the previous training system. The initial and or annual in-service training does not exist for staff S, staff Z, staff CC staff DD, staff GG staff HH, staff LL, and staff MM.
Staff E stated the facility would work on the employees emergency preparedness in-service training.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2016, 2017 and 2018 as the documents do not exist.

On 07/09/19 at 1:52 pm the surveyor asked Staff Q was asked to provide the annual emergency generator fuel quality testing documentation for 2016, 2017 and 2018. Staff Q stated the annual emergency generator fuel quality tests have never been done and the documents do not exist.

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

Findings:

On 07/09/19 at 4:17 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 07/09/19 at 4:17 pm the surveyor asked staff Q why there were deadbolts on the corridor doors which would take two actions to open. Staff Q stated the deadbolts have always been there and they did not really know why the deadbolts were there. Staff Q 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 observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 07/09/19 at 4:16 pm one ABC class fire extinguisher was observed in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 07/09/19 at 4:16 pm the surveyor asked staff Q why there was no placard on the fire extinguisher in the kitchen. Staff Q stated he would get with their fire service vendor to get the appropriate placard for the fire extinguisher installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over ignition sources.

Findings:

On 07/09/19 at 3:34 pm the surveyor observed one ABHR dispenser installed over a light switch in the volunteers office.

On 07/09/19 at 3:34 pm the surveyor asked Staff Q why the ABHR was installed over the light switch. Staff Q stated he did not know but will have it reinstalled correctly.

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 07/09/19 at 3:54 pm the surveyor stated to Staff Q the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff Q 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 07/09/18 at 2:33 pm the surveyor asked Staff Q for the annual fire rated door assembly inspections. Staff Q stated the inspection was not completed for 2017, 2018 and the documentation does not exist.

Based on obsevation and interview the facility failed to ensure space heaters used within the facility had documentation that the heating elements did not exceed 212 degrees Fahrenheit as required.

Findings:

On 07/09/19 at 4:08 pm the surveyor observed two space heaters in staff offices.

On 07/09/19 at 4:08 pm the surveyor asked staff Q if they have the manufacturers documentation indicating the heating elements to each of the space heaters do not go over 212 degrees Fahrenheit. Staff Q stated they would look to get it. Staff Q did not provide the documentation as it did 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 07/09/19 at 2:35 pm the surveyor asked staff Q for the EES and Medical Gas building system risk assessments. Staff Q 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 electrical receptacles in patient care areas were tested annually as required.

Findings:

Record review showed the facility did not test patient care electrical receptacles for 2016, 2017 and 2018.

On 07/09/19 at 3:33 pm the surveyor asked Staff Q for the patient care area electrical receptacle testing for 2016, 2017 and 2018. Staff Q failed to provide the impedance testing documentation for the facility. The electrical receptacle testing documentation does not exist for 2016, 2017 and 2018.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2016, 2017 and 2018 as the documents do not exist.

On 07/09/19 at 1:52 pm the surveyor asked Staff Q was asked to provide the annual emergency generator fuel quality testing documentation for 2016, 2017 and 2018. Staff Q stated the annual emergency generator fuel quality tests have never been done and the documents do not exist.