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Based on record review and interview the facility failed to document an emergency preparedness program.

The findings include:

Cross Reference E0004: Based on record review and interview the facility failed to develop an emergency preparedness plan.

During record review on August 10, 2018, the facility failed to document an emergency preparedness plan.

In an interview on August 10, 2018, the Risk Manager acknowledged the facility has no emergency preparedness plan.

Based on record review and interview the facility failed to develop an emergency preparedness plan.

The findings include:

During record review August 10, 2018, the facility failed to document the establishment of an emergency preparedness plan.

In an interview on August 10, 2018, the Risk Manager acknowledged the facility failed to establish an emergency preparedness plan.

Based on observation and interview the facility has installed an alcohol-based hand-rub dispenser (abhd) above an ignition
source (light switch) prohibited by NFPA 101(2012 edition) chapter 19.3.2.6 (8).

The findings include:

During a tour August 10, 2018 from 12:30 PM to 1:30 PM, in room 5, an abhd was observed installed directly over a light switch.

In an interview on August 10, 2018 at 1:30 PM with the Risk Manager it was acknowledged the abhd in room 5 was installed directly above a light switch.

Based on record review, observation, and interview the facility failed to document the inspection and service of their fire dampers every six years as required by NFPA 80 (2010 edition) chapter 19.4.1.1. NFPA 101 (2012 edition) chapter 19.5.2.1, 9.2. NFPA 90 A (2012 edition) chapter 5.4.8.1

The findings include:

During record review August 10, 2018 the facility failed to document the inspection and testing of their fire dampers.

During a tour August 10, 2018 from 12:30 PM to 1:30 PM, fire dampers were visible in the exhaust vent in the toxicology laboratory and in the exhaust vent in room 4.

In an interview on August 10, 2018 at 1:30 with the Risk Manager acknowledged the fire dampers in the two rooms and acknowledged fire dampers in the exhaust vents throughout the facility.

Based on record review and interview the facility failed to document the annual inspection of the facility fire doors as required by NFPA 80(2010 edition) chapter 5.2.4. NFPA 101(2012 edition) chapter 7.2.1.15.2.

The findings include:

During record review August 10, 2018, the facility failed to document the annual inspection of their fire doors.

In an interview on August 10, 2018 at 1:30 PM, the Risk Manager acknowledged the facility did not conduct an annual fire door inspection.

Based on record review and an interview the facility failed to document the annual testing of their non-hospital grade receptacles as required by NFPA 99 (2012 edition) chapter 6.3.4.1.3.

The findings include:

During record review August 10, 2018, the facility failed to document the testing of the facility's non-hospital grade receptacles.

In an interview on August 10, 2018 at 1:40 PM, the Maintenance Director acknowledged the receptacle testing was not conducted.

Based on record review and interview the facility failed to document the annual inspection of the facility's main and feeder circuit breakers and failed to document a plan for exercising the facility's main and feeder circuit breakers. NFPA 99 (2012 edition) chapter 6.4.4.1.2.1.

The findings include:

During record review August 10, 2018 the facility failed to document the inspection of the facility's main and feeder circuit breakers and failed to document a plan for exercising the facility's main and feeder circuit breakers.

In an interview on August 10, 2018 at 1:40 PM, the Maintenance Director acknowledged the facility's main and feeder circuit breakers were not inspected and a plan for exercising the facility's main and feeder circuit breakers was not available.

Based on observation and interview the facility is using re-locatable power strips as a receptacle expander and using re-locatable power strips in a manner outside their UL 1363 listing. NFPA 99 (2012 edition ) chapter 10.2.3.6,10.2.4. NFPA 70 (2011 edition) article 400-8.

The findings include:

During a tour August 10, 2018 from 12:30 PM to 1:30 PM in room 125, two re-locatable power strips were visible supplying power to four appliances. There was only a duplex receptacle available.

During an interview on August 10, 2018 at 1:30 PM the Risk Manager acknowledged the re-locatable power strips were in use as a receptacle expander.