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A Life Safety Code Validation Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 485.623(d).

Survey Date: 05/09/17

Facility Number: 005029
Provider Number: 151320
AIM Number: 100269610A

At this Life Safety Code Validation survey, Jay County Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(d), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).

The facility consists of four buildings; the Main Hospital (Bldg. 01), the Ambulatory Surgery Center (Bldg. 03), Jay Family Medicine Building (Bldg. 07), and the Medical Office Building (Bldg. 08).

Main Hospital (Bldg. 01) is a two story, fully sprinklered building of Type II (222) construction and has a fire alarm system with smoke detection in the patient rooms, corridors, and areas open to the corridors. (Bldg. 01) was surveyed for compliance with LSC Chapter 19, Existing Health Care Occupancies facility. The facility has a capacity of 35 and had a census of 22 at the time of this visit. All areas where the patients have customary access are sprinklered. All areas providing facility services are sprinklered with exception of the IT room and two office closets.

The Ambulatory Surgery Center (Bldg. 03) is a one story, fully sprinklered building of Type V (111) construction and has a fire alarm system with smoke detection in the patient suites, corridors, OR rooms and areas open to the corridors. (Bldg. 03) was surveyed for compliance with LSC Chapter 19, Existing Health Care Occupancies facility. All areas where the patients have customary access are sprinkered. All areas providing facility services are sprinklered.

Jay Family Medicine Building (Bldg. 07) is a one story, nonsprinklered building of Type V (000) construction was surveyed for compliance with Chapter 39, Existing Business Occupancies. The facility does not have a fire alarm system.

The Business Office building, (Bldg. 08) a two story, nonsprinklered building of Type V (000) construction was surveyed for compliance with Chapter 39, Existing Business Occupancies. The facility does not have a fire alarm system.


Findings include:

Based on observation, record review and interview, the facility failed to ensure the corridor door to 1 of 1 hazardous areas such as a combustible storage room over 50 square feet was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect 25 people in the front lobby (Bld 01) and the facility failed to ensure the corridor door to 1 of 1 hazardous soiled Utility rooms were provided with a self-closing device which would cause the door to automatically close and latch into the door frame. (Bld 03) This deficient practice could affect 2 patients in the OR (see tag K321) and the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants (Bld 01)and the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. (Bld 03)This deficient practice affects all occupants (see tag K346) and the facility failed to ensure complete automatic sprinkler system was provided for 2 of 2 closets in and 1 of 1 IT rooms accordance with NFPA 13-2010, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice could affect up to 30 people in two first floor smoke compartments (see tag K351) and the facility failed to provide written documentation or other evidence the sprinkler system gauges and valves had been inspected for 12 of 12 past months. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 Requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal supply pressure is being maintained. NFPA 25, 13.3.2.1.1 states valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. This deficient practice could affect all patients, staff, and visitors in the facility (Bld 01and Bld 03) (see tag K353) and the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire sprinkler system has to be placed out of service for ten hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants (Bld 01 and Bld 03)(see tag K354) and the facility failed to conduct quarterly fire drills for 1 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice affects all staff and patients (for Bld 01) (see tag K712) and the facility failed to ensure 2 of 2 emergency generators ran 30 minutes under load monthly and was allowed a 5 minute cool down period after a load test. NFPA 99, 2012, Chapter 6.4.4.1.1.4(a), requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, 2010. Chapter 8.4.2 states diesel generators sets in service shall be exercised at least once a month for a minimum of 30 minutes and 8.4.2.4 states Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes. 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all occupants(for Bld 01 and 03)(see tag K918) and the facility failed to ensure a minimum distance of at least five feet separated combustible materials from oxygen storage equipment in 1 of 1 oxygen storage areas. NFPA 99, 11.3.2.3 requires oxidizing gases such as oxygen shall be separated from combustibles by one of the following: (1) a minimum distance of 20 feet. (2) a minimum distance of 5 feet if the required storage location is protected by an automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. This deficient practice could affect 20 people in one smoke compartment on the first floor (for Bld 01) (see tag K927) and the facility failed to ensure 1 of 2 fire barriers that separated other occupancies were protected to maintain the one hour fire resistance rating of the fire barrier. NFPA 101 2012 edition 8.3.5.6.1 states membrane penetrations for cables cable trays conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a membrane of a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. 8.3.5.6.2 The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Test of Through Penetration Fire stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops. This deficient practice could affect all occupants (for Bld 03) (see tag K131) and the facility failed to ensure there were battery-powered lighting for 2 of 2 anesthesia areas. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provided within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect two patients, and staff during surgery (see tag K911) and the facility failed to ensure there were ground-fault circuit interrupters (GFCI) for 2 of 2 wet procedure locations in the O.R. This deficient practice could affect two patients, and staff during surgery (for Bld 03) (see tag K913) and the facility failed to ensure testing for 6 of 6 emergency battery powered lighting units. NFPA 101 in 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be maintained. LSC 7.9.3.1.1 testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with approval of the authority having jurisdiction
(3) Functional testing shall be conducted annually for a minimum of 1 ½ hours if the emergency lighting is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the test.
(5) Written records of visual inspections and tests shall be kept by the owner for inspection for the authority having jurisdiction
This deficient practice could affect all occupants if the facility were required to evacuate in an emergency during a loss of normal power (Bld 07) (see tag K300) and the facility failed to ensure documentation for the preventative maintenance of 1 of 1 battery operated smoke alarms in the medical office building. NFPA 101 in 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be maintained. This deficient practice could affect all residents, staff, and visitors (Bld 08) (see tag K300).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation, record review and interview, the facility failed to ensure the corridor door to 1 of 1 hazardous areas such as a combustible storage room over 50 square feet was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect 25 people in the front lobby (Bld 01) and the facility failed to ensure the corridor door to 1 of 1 hazardous soiled Utility rooms were provided with a self-closing device which would cause the door to automatically close and latch into the door frame. (Bld 03) This deficient practice could affect 2 patients in the OR (see tag K321) and the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants (Bld 01)and the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. (Bld 03)This deficient practice affects all occupants (see tag K346) and the facility failed to ensure complete automatic sprinkler system was provided for 2 of 2 closets in and 1 of 1 IT rooms accordance with NFPA 13-2010, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice could affect up to 30 people in two first floor smoke compartments (see tag K351) and the facility failed to provide written documentation or other evidence the sprinkler system gauges and valves had been inspected for 12 of 12 past months. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 Requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal supply pressure is being maintained. NFPA 25, 13.3.2.1.1 states valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. This deficient practice could affect all patients, staff, and visitors in the facility (Bld 01and Bld 03) (see tag K353) and the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire sprinkler system has to be placed out of service for ten hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants (Bld 01 and Bld 03)(see tag K354) and the facility failed to conduct quarterly fire drills for 1 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice affects all staff and patients (for Bld 01) (see tag K712) and the facility failed to ensure 2 of 2 emergency generators ran 30 minutes under load monthly and was allowed a 5 minute cool down period after a load test. NFPA 99, 2012, Chapter 6.4.4.1.1.4(a), requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, 2010. Chapter 8.4.2 states diesel generators sets in service shall be exercised at least once a month for a minimum of 30 minutes and 8.4.2.4 states Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes. 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all occupants(for Bld 01 and 03)(see tag K918) and the facility failed to ensure a minimum distance of at least five feet separated combustible materials from oxygen storage equipment in 1 of 1 oxygen storage areas. NFPA 99, 11.3.2.3 requires oxidizing gases such as oxygen shall be separated from combustibles by one of the following: (1) a minimum distance of 20 feet. (2) a minimum distance of 5 feet if the required storage location is protected by an automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. This deficient practice could affect 20 people in one smoke compartment on the first floor (for Bld 01) (see tag K927) and the facility failed to ensure 1 of 2 fire barriers that separated other occupancies were protected to maintain the one hour fire resistance rating of the fire barrier. NFPA 101 2012 edition 8.3.5.6.1 states membrane penetrations for cables cable trays conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a membrane of a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. 8.3.5.6.2 The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Test of Through Penetration Fire stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops. This deficient practice could affect all occupants (for Bld 03) (see tag K131) and the facility failed to ensure there were battery-powered lighting for 2 of 2 anesthesia areas. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provided within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect two patients, and staff during surgery (see tag K911) and the facility failed to ensure there were ground-fault circuit interrupters (GFCI) for 2 of 2 wet procedure locations in the O.R. This deficient practice could affect two patients, and staff during surgery (for Bld 03) (see tag K913) and the facility failed to ensure testing for 6 of 6 emergency battery powered lighting units. NFPA 101 in 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be maintained. LSC 7.9.3.1.1 testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with approval of the authority having jurisdiction
(3) Functional testing shall be conducted annually for a minimum of 1 ½ hours if the emergency lighting is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the test.
(5) Written records of visual inspections and tests shall be kept by the owner for inspection for the authority having jurisdiction
This deficient practice could affect all occupants if the facility were required to evacuate in an emergency during a loss of normal power (Bld 07) (see tag K300) and the facility failed to ensure documentation for the preventative maintenance of 1 of 1 battery operated smoke alarms in the medical office building. NFPA 101 in 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be maintained. This deficient practice could affect all residents, staff, and visitors (Bld 08) (see tag K300).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.


Findings include:

1. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than four hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

2. Based on observations during a tour of the facility with the Maintenance Supervisor on 5/09/17 at 12:04 p.m., the door to the gift shop storage room from the volunteer office; which was open to the corridor, contained a large quantity of combustible items, and measured over 50 square feet; was not equipped with a self-closing device. Based on interview, this was acknowledged by the Maintenance Supervisor at the time of observation.

3. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 OB soiled utility room doors was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect 10 patients in OB.

4. Based on observations during a tour of the facility with the Vice President of Information Support Operations on 05/09/17 at 11:00 a.m., the door to the OB soiled utility room, which contained soiled linen and trash greater than 64 gallons, was equipped with a self-closing device but did not latch into the frame. Based on interview, this was acknowledged by the Vice President of Information Support Operations at the time of observation.

5. Based on observation and interview, the facility failed to ensure 1 of 1 soiled utility room in behavioral health were separated from other spaces by smoke resisting partitions and doors. This deficient could affect up to 12 patients in behavior health.

6. Based on observations during a tour of the facility with the Maintenance Supervisor on 5/09/17 at 11:27 a.m., the behavior health soiled utility room, which contained soiled linen and trash greater than 64 gallons, contained four unsealed half inch penetrations in the ceiling around conduits. Based on an interview at the time of observation, the Maintenance Supervisor acknowledged the penetrations and provided the measurements.

7. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than four hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

8. Based on observations during a tour of the facility with the Maintenance Supervisor on 05/09/17 between 10:50 a.m. and 1:10 p.m., the following areas lacked sprinkler coverage:
a) The Marketing Office closet that was used for storage did not contain a sprinkler in the closet.
b) The Customer Relations Office closet that was used for storage did not contain a sprinkler in the closet.
c) The back half of the IT room was not covered by the one sprinkler in the room. The one sprinkler head was located near the door would not provide coverage to the back of the room because a little past center of the room there was an IT tower six inches below the bottom of a 11 inch header leaving only a six inch gap for water to pass through.

9. Based on an interview at the time of observation, the Maintenance Supervisor acknowledged the aforementioned areas lacked sprinkler coverage.

10. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 10:11 a.m., there was no monthly inspection of all of the sprinkler system's gauges and valves available for review. Only one gauge out of five were inspected monthly. During an interview at the time of record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged there was no written documentation available to show all of the sprinkler system's gauges and valves had been inspected monthly.

11. Based on record review, observation and interview; the facility failed to ensure 1 of 4 sprinkler system gauges were replaced every 5 years or documented as tested every 5 years by comparison with a calibrated gauge. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.3.2.1 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all patients, visitors and staff in the facility.

12. Based on observations during a tour of the facility with the Maintenance Supervisor on 5/09/17 at 11:55 a.m., the three sprinkler gauges on the pre-action riser for the imaging center had a date of 2011 listed on the face of the sprinkler gauge. Based on interview at the time of the observation, the Maintenance Supervisor acknowledged the sprinkler gauge was more than five years old.

13. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than 10 hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

14. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., there was no documentation for a second shift fire drill in the third quarter of 2016. Based on interview at the time of record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

15. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 10:05 a.m., the generator log form documented the spark-ignited generator was tested monthly, however there was no documentation on the form that showed the generator ran for at least 30 minutes under load or had a cool down time of at least 5 minutes following its load test. Based on interview at the time of record review, the Maintenance Supervisor stated the generator did run under load for 30 minutes and had a cool down over five minutes but the times were not documented.
3.1-19(b)

16. Based on observation during a tour of the facility with the Maintenance Supervisor on 05/09/17 at 11:37 p.m., the liquid oxygen containers were stored in the Decontamination room next to and touching plastic barrels filled with decontamination supplies. Based on interview at the time of observation, the Maintenance Supervisor acknowledged combustible materials were stored within five feet of stationary liquid oxygen containers.
3.1-19(b)

17. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage/transfer location was provided with a sign indicating that transferring is occurring. NFPA 99 11.5.2.3.1(3) states, the area is posted with signs indicating that trans-filling is occurring and that smoking is the immediate area is not permitted. This deficient practice could affect 20 people in one smoke compartment on the first floor.

18. Based on observation during a tour of the facility with the Maintenance Supervisor on 05/09/17 at 11:37 p.m., the oxygen storage/transfer room was labeled Decontamination room, which dose have a concert floor and mechanically vented, contained three liquid oxygen containers and one oxygen cylinders. The door to this room lacked a sign indicating that transferring of oxygen occurs in this location and oxygen was stored. Base on interview this was acknowledged by the Maintenance Supervisor at the time of observation.
3.1-19(b)

19. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen trans-filling rooms was protected with a one hour fire-resistive construction by having a self-closing door in accordance with 2012 NFPA 99 11.5.2.3.1(1). This deficient practice could affect 20 people in one smoke compartment on the first floor.

20. Based on observation during a tour of the facility with the Maintenance Supervisor on 05/09/17 at 11:37 p.m., the oxygen storage/transfer room did have the proper rated door, but the door was not self-closing. Based on interview at the time of observation, the Director of Plant Operations acknowledged the aforementioned condition.

21. Based on observations during a tour of the facility with the Maintenance Supervisor and the Vice President of Information Support Operations on 5/09/17 at 2:20 p.m., in the north fire wall that separates the surgery area form an office occupancy contained 10 unsealed one inch penetrations around piping, wires, and conduits. Based on interview at the time of observation, the Maintenance Supervisor and the Vice President of Information Support Operations acknowledged the penetrations.

22. Based on observations during a tour of the facility with the Maintenance Supervisor on 5/09/17 at 2:00 p.m., the door to soiled utility room; which contained soiled linen, trash, and medical waste; was not equipped with a self-closing device. Based on interview, this was acknowledged by the Maintenance Supervisor at the time of observation.

23. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than four hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

24. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 10:11 a.m., there was no monthly inspection of the sprinkler system's gauges and valves available for review. During an interview at the time of record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged there was no written documentation available to show the sprinkler system's gauges and valves had been inspected monthly.

25. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 9:18 a.m., the facility provided fire watch documentation but it was incomplete due to the following:
a) The fire watch plan did not distinguish between fire alarm outage and sprinkler system outage.
b) The fire watch plan did not state that only trained personnel can conduct a fire watch.
c) The fire watch plan did not indicate the person(s) conducting the fire watch shall be dedicated to the fire watch and have no other duties.
d) The fire watch plan did not list the call to Indiana State Department of Health, the insurance company, hospital leadership, and the fire alarm monitoring company when after the system has been down more than 10 hours.
Based on an interview record review, the Maintenance Supervisor and Vice President of Information Support Operations acknowledged the aforementioned condition.

26. Based on observations during a tour of the facility with the Vice President of Information Support Operations and the Maintenance Supervisor on 5/09/17 at 2:15 p.m., operating rooms one and two did not have battery-powered lighting. Based on interview at the time of observation, the Maintenance Supervisor and the Vice President of Information Support Operations acknowledged both operating rooms that used deep sedation and general anesthesia did not have backup battery-powered lighting.

27. Based on observations during a tour of the facility with the Maintenance Supervisor and the Vice President of Information Support Operations on 5/09/17 at 2:14 p.m., all of the electrical outlets in O.R. rooms one and two did not have GFCI protection. Based on interview at the time of observation, the Maintenance Supervisor and the Vice President of Information Support Operations acknowledged all outlets were not GFCI protected and stated there was not a risk assessment conducted to show the outlets could be unprotected by a GFCI.

28. Based on record review with the Maintenance Supervisor and Vice President of Information Support Operations on 05/09/17 at 10:05 a.m., the generator log form documented the spark-ignited generator was tested monthly, however there was no documentation on the form that showed the generator ran for at least 30 minutes under load or had a cool down time of at least 5 minutes following its load test. Based on interview at the time of record review, the Maintenance Supervisor stated the generator did run under load for 30 minutes and had a cool down over five minutes but the times were not documented.
3.1-19(b)

29. Based on observations during a tour of the facility with the Vice President of Information Support Operations on 5/09/17 between 11:00 a.m. 11:30 am, there were six battery power emergency lights observed in the facility. Based on a records review with the Maintenance Supervisor at 1:15 p.m., no written records of an annual 1 ½ hour functional test or a 30 second month test was available for review. Based on interview at the time of record review, the Maintenance Supervisor acknowledged no documentation was available for review.

30. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 hazardous rooms with fuel fired equipment, was provided with a fire rated door. LSC 39.3.2.1 states hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops shall be protected in accordance with section 8.7. LSC 8.7.1.3 doors in barriers required to have a fire resistant rating shall have a minimum ¾-hour fire protection rating and shall be self-closing in accordance with 7.2.1.8. This deficient practice could affect all occupants of the building.

31. Based on observations during a tour of the facility with the Vice President of Information Support Operations on 5/09/17 at 11:10 a.m., the door to the furnace room, which contained a fuel fired furnace and was not sprinkled, did not have a fire rated door. Based on interview, this was acknowledged by the Vice President of Information Support Operations at the time of observation.

32. Based on observations during a tour of the facility with the Vice President of Information Support Operations on 5/09/17 at 10:30 a.m., there was no report available of the battery operated smoke alarm tested for functionality on a monthly basis during the past twelve months. Based on interview, this was acknowledged by the Vice President of Information Support Operations at the time of record review.

Based on document review and interview, the facility failed to follow policy Transfer or Discharge of Individuals to Another Institution, in 1 of 2 (Pt #2) transfers that lacked complete documentation of the transfer form.

Findings include:

1. Review of policy Transfer or Discharge of Individuals to Another Institution, page 2, V. Procedure, A 1 and 2 "...document acceptance of transfer...will send receiving facility copies of all medical records related to the individuals's emergency condition".

2. Review of Pt #2 medical records lacked documentation of "Accepted by/Report given to...Information Sent with Patient".

3. Interview on 05/11/17 at 4:20 pm with P 62 Clinical Informatics Specialist (RN) and P50 CNO confirmed lack of complete documentation on Pt #2's transfer form.

Based on document review and interview, the facility failed to follow accepted standards of practice from the American Association of Blood Banks for the administration of blood products for three of six transfusions reviewed (P#21, P#22, and P#24).

Findings include:

1. Review of a Jay County Hospital policy/procedure titled "Transfusion of Packed Red Blood Cells", last revised 6/13, indicated the following:
a. "11. Obtain and document a full set of vital signs 15-30 minutes prior to start or receiving blood from lab and document."
b. "16. After 15 minutes, obtain and document a second set of vital signs on............"
c. "19. After the blood has completely infused, obtain a final set of vital signs and document on the Crossmatch Transfusion Report or EMR (Electronic Medical Records) within 30 minutes post transfusion."

2. Transfusion P#21 and P#24 had Start time and Pre vitals taken at the same time, P#22 had the post vitals taken at 46 minutes instead of 30 minutes, and P#24 had the post vitals taken at almost 2 hours post.

3. Interview on 5/9/19 at 10:00am, with SP#5 (Staff Person - RN) confirmed the above information during the electronic records review.

Based on document review and interview, the facility failed to ensure that the Director of Psychiatric Nursing Services had a master's degree in Psychiatric & Mental Health nursing, or its equivalent, or was qualified by education and experience in the care of the mentally ill for 1 Prospective Payment System (PPS) psychiatric inpatient unit.

Findings include:

1. Review of N11 (RN) personnel file, lacked documentation of a master's degree or current education in behavioral health. Last documentation of education was 2014.

2. Interview with N11 (RN), P66 Director of Behavioral Health Unit and P50 CNO on 05/11/17 at approximately 1 pm confirmed lack of recent education or master's degree for N11.