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Based on record review and interview the facility failed to ensure the development of written transfer agreements, memorandum of understanding (MOU) or contracted agreements with other facilities identified in their emergency procedure manual to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Findings:

On 03/22/19 at 11:17 am the surveyor asked the for documentation of transfer agreement, memorandum of understanding or contracted arrangements with other facilities to receive patients in the event of an disaster and St. John's Sapulpa would not be able to shelter in place. The facility emergency preparedness manual included the following alternate care sites, Sapulpa Junior Senior High School, and The first church of God Sapulpa. Staff O stated a written agreement, contract, or Memorandum of Understanding did not exist, the facility safety officer only had verbal agreements with Sapulpa Junior Senior High School and The First Church of God Sapulpa. The documentation did not exist.

Based on record review and interview the facility failed to ensure annual and initial in-service training for new and existing staff, individuals providing on-site services under arrangement, and volunteers on the emergency preparedness plan for 16 (staff P, staff Q, staff R, staff S, staff T, staff U, staff V, staff W, staff X, staff Y, staff Z, staff AA, staff BB, staff CC, staff DD and staff EE) of 27 employee files.

Findings:

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


Staff P with the date of hire 10/26/15 had not received 2016 annual in-service training for the facility emergency preparedness plan.

Staff Q with the date of hire 03/26/13 had not received initial or 2014, 2016 annual in-service training for the facility emergency preparedness plan.

Staff R with the date of hire had not received 2016 annual in-service training for the facility emergency preparedness plan.

Staff S with the date of hire 08/24/10 had not received initial or 2011-2013, 2016 annual in-service training for the facility emergency preparedness plan.

Staff T with the date of hire 10/18/11 had not received initial or 2012, 2015-2016 annual in-service training for the facility emergency preparedness plan.

Staff U with the date of hire 03/01/96 had not received initial or 1997-2013, annual in-service training for the facility emergency preparedness plan.

Staff V with the date of hire 02/02/15 had not received 2016 annual in-service training for the facility emergency preparedness plan.

Staff W with the date of hire 01/28/14 had not received 2016 annual in-service training for the facility emergency preparedness plan.

Staff X with the date of hire 12/22/14 had not received 2016-2018 annual in-service training for the facility emergency preparedness plan.

Staff Y with the date of hire 05/18/13 had not received initial or 2015 annual in-service training for the facility emergency preparedness plan.

Staff Z with the date of hire 01/29/08 had not received initial or 2009-2014, 2016 annual in-service training for the facility emergency preparedness plan.

Staff AA with the date of hire 01/11/16 had not received initial in-service training for the facility emergency preparedness plan.

Staff BB with the date of hire 03/13/12 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff CC with the date of hire 09/03/13 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff DD with the date of hire 08/02/04 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff EE with the date of hire 11/14/16 had not received initial or annual in-service training for the facility emergency preparedness plan.


The emergency preparedness training records for initial and or annual in-service do not exist for Staff P, Staff Q, Staff R, Staff S, Staff T, Staff U, Staff V, Staff W, Staff X, Staff Y, Staff Z, Staff AA, Staff BB, Staff CC, Staff DD, and Staff EE.

On 03/21/19 at 01:15 pm the surveyor requested St. John's Sapulpa training transcripts of new and existing staff, volunteers, and individuals providing on-site services under arrangement.
On 03/22/19 at 11:17 am following review of the requested documentation, the surveyor explained to Staff D and Staff O that no evidence of initial and/or annual staff training documentation existed for some staff training on emergency preparedness. The training transcripts provided to the surveyor did not show courses completed. The surveyor asked Staff D the facility process for training on emergency preparedness. Staff O stated the facility provides both initial and annual training for employees related to Emergency Preparedness. Staff D provided a statement as requested regarding the training process for the agency. "R1 (medical records/admissions staff BB, staff CC and staff DD) unable to find evidence of training. Will work with the R1 director on whether or not the training has been done; how it is done and/or how it will be completed ongoing. If needed, will work with St. John Health System and Safety Department Education on utilizing SJHS education for R1 associates." The surveyor was unable to verify the documentation existed for some staff.


Based on record review and interview the facility failed to demonstrate education and instruction to staff of a community based exercise, tabletop exercise, or full-scale exercise to demonstrate staff knowledge of emergency procedures.

Findings:

On 03/22/19 at 9:38 am Staff O was asked to provide documentation such as a sign-in sheet, meeting minutes, to verify staff received training on drills or exercises dated March 08, 2018 and November 15, 2018 completed by the facility. Staff O stated according to the facility Safety officer they did not have sign-in sheets for the exercises the staff participated in or trained for. The surveyor stated, CMS requires facilities to be able to demonstrate documentation exists for training, drills and exercises in order to verify staff knowledge of emergency procedures, and to identify gaps and areas for improvement. The document did not exist to verify staff received in-service training for exercise training's.

Based on observation and interview, the facility failed to ensure each egress access door could be opened with only one action as required.

Findings:

On 03/22/19 at 10:13 am a padlock was observed on the door to OR#2 with a turn knob on the egress side.

On 03/22/19 at 10:13 am the survyeor asked staff GG why the padlock was installed on the door to OR#2. Staff GG stated he did not know why but will get it corrected.

On 03/22/19 at 10:41 am a keyed deadbolt was observed on patient room 2502 with a keyed deadbolt on the egress side too.

On 03/22/19 at 10:41 am the surveyor asked staff GG if each staff member on the unit had keys to each of the patients rooms which had keyed deadbolts and he stated no.

Based on observed and interview the facility failed to ensure hazardous areas were protected as required.

Findings:

On 03/22/19 at 9:30 am the surveyor observed five pipes with the annular spaces not filled with a fire resistant material in the IT closet which would allow fire and smoke to spread into other areas of the facility.

On 03/22/19 at 9:45 am the surveyor observed three pipes in the communication closet with the annular spaces not filled with a fire resistant material which would allow fire and smoke to spread into other areas of the facility.

On 03/22/19 at 9:45 am Staff GG stated he would get each of the open areas of the pipes filled with appropriate material that is fire resistant.

Based on record review and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were followed as required.

Findings:

Record review showed the facility has not documented manometer readings for the HVAC system that serves the surgical suite. The manometer documentation does not exist.

On 03/21/19 at 11:09 am the surveyor asked staff GG how they document manometer readings in order to determine changing HVAC filters that serve the surgical suite. Staff GG stated they change the filters every six months but will start documenting manometer readings as required.

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 assessments were not completed.

On 03/21/19 at 11:23 am the surveyor asked Staff GG for the EES and Medical Gas building system risk assessments. Staff GG stated they were not aware of the requirement but will get the medical gas and EES building system risk assessments started and completed.

Based on observation and interview the facility failed to ensure extension cords were not used as a substitute for fixed wiring of a structure and are only used temporarily then removed immediately upon the completion of the purpose for which it was installed and meets the conditions of NFPA 99, 2012 Edition, 10.2.4.

Findings:

On 03/22/19 at 12:29 pm the surveyor observed a non-UL listed power tap in OR#2 connected to the anestestha machine with several other electrical biomedical items connected to it.

On 03/22/19 at 12:29 pm the surveyor stated to staff GG that an PCREE surge suppression device must meet UL1363 or UL-60601-1 as required by CMS. Staff GG stated he will take out the non-UL listed power tap and replace it with only a CMS approved device.