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Based on review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to provide a written Emergency Preparedness Plan that included a facility-based and community-based risk assessment, utilizing an all-hazards approach.

Findings include:

1. Documentation review on August 3, 2020, at 9:00 a.m., revealed the submitted EP Plan did not include a facility-based and community-based risk assessment, utilizing an all-hazards approach.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the EP Plan failed to address all requirements for subsistence needs for staff and patients.

Findings include:

1. Documentation review on August 3, 2020, at 9:00 a.m., revealed the EP Plan did not contain a fire watch policy for impairments of systems in accordance with Section (C) Fire Detection, Extinguishing and Alarm Systems.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to maintain documentation of arrangements with other facilities.

Findings include:

1. Documentation review on August 3, 2020, at 9:00 a.m., revealed the facility failed to develop arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to meet all requirements for a program to train and test staff.

Findings include:

1. Documentation review on August 3, 2020, at 9:00 a.m., revealed the EP Plan submitted for review did not contain a written program for the training and knowledge assessment of new and existing employees.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to maintain documentation of staff training and testing.

Findings include:

1. Documentation review on August 3, 2020, at 9:00 a.m., revealed the facility lacked documentation of initial and annual training for all new and existing staff on the EP Plan policies and procedures.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to maintain annual documentation of training exercises to test the emergency plan.

Findings include:

1. Documentation review on August 3, 2020, at 9:00 a.m., revealed the facility failed to conduct a full-scale facility based disaster exercise within the last twelve months.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined that the facility failed to meet requirements for the maintenance and testing of the emergency generator.

Findings include:

1. Documentation review on August 3, 2020, revealed the facility failed to perform all maintenance and testing requirements of NFPA 110.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the health care occupancy from other occupancies, in two instances affecting the entire facility.

Findings include:

1. Observation on August 3, 2020, revealed the following issues with the two-hour fire resistance rated occupancy separation barrier wall seperating the basement equipment room and the boiler plant:

a) 9:40 a.m., the automatic closer was unhooked from the two hour fire restive door seperating the equipment room from the boiler plant, not allowing the door to close and latch when tested;
b) 2:24 p.m., the wall above the doors seperating the euipment room from the boiler plant had multiple unsealed conduit penetrations.

Interview with the Facility Staff on August 3, 2020, at 2:00 p.m., confirmed the deficiencies in the two-hour rated occupancy separation wall.

Based on observation and interview, it was determined that the facility failed to maintain the fire barrier doors, on one of four floors.

Findings include:

1. Observation on August 3, 2020 revealed door # 007 for stairwell #2 in the basement failed to positively latch when tested.

Interview with Facility staff on August 3, 2020, at 2:00 p.m., confirmed the door deficiency.

Based on documentation review and interview, it was determined that the facility failed to maintain emergency lighting in one instance, affecting the entire facility.

Findings include:

1. Documentation review on August 3, 2020, at 9:00 a.m., revealed the facility failed to perform monthly 30 second testing and annual 90 minute testing of emergency lighting units.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosure in 8 instances, affecting 10 of 14 smoke compartments.

Findings include:

1. Observation on August 3, 2020, revealed the following vertical opening enclosure deficiencies:

a) 9:17 a.m., there was an unsealed pipe penetration in the ceiling of the basement mechanical room R0005;
b) 9:30 a.m. there was missing cement block and pipe penetrations in the wall above the door leading into stairwell 0027 in the basement;
c) 9:32 a.m., there was an unsealed conduit penetration above the ceiling at the door leading into the number three elevator in the basement;
d) 10:05 a.m., there was unsealed conduit penetration in the floor of the fourth floor penthouse 0401;
e) 11:02 a.m., there was an unsealed MC cable penetration in the elevator shaft above the ceiling at the doors leading into the number three elevator on the second floor;
f) 11:06 a.m., there was an unsealed conduit penetration in the floor and in the ceiling in the IT closet on the second floor by elevator number three;
g) 11:20 a.m., there was an unsealed wire penetration and a penetration sealed with an unapproved substance above the ceiling at door 251 for stairwell #4 on the second floor;

Interview with Facility Staff on August 3, 2020, at 2:00 p.m.,confirmed the unsealed vertical opening enclosure deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain hazardous area enclosures in one instance, affecting one out of fourteen smoke compartments.

Findings include:

1. Observation on August 3, 2020, at 12:50 p.m., revealed the door to the emergency department supply room, next to behavioral health room #9, failed to positive latch in its frame upon testing.

Interview with the Facility Staff on August 3, 2020, at 2:00 p.m., confirmed the hazardous area deficiency.

Based on observation and interview, it was determined the facility failed to maintain the automatic fire alarm system in xx instances, in xx of fourteen smoke compartments.

Findings include:

1. Observation on August 3, 2020, revealed the following:

a) 9:45 a.m., there was storage in front of the fire alarm pull station in the basement rear hallway;
b) 12:45 p.m., there was storage in front of the fire alarm pull station in the first floor emergency department, by the entrance to the nursing lounge.

Interview with the Facility Staff on August 3, 2020, at 2:00 p.m., confirmed the smoke detection deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in xx instances, in xx of 14 smoke compartments.

Findings include:

1. Observation on August 3, 2020, revealed the following automatic sprinkler system deficiencies:

a) 9:39 a.m., the facility failed to maintain storage below the 18 inch sprinkler head plane, in the pharmacy storage room;

Interview with the Facility Staff on August 3, 2020, at 2:00 p.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the portable fire extinguishers in XX instances affecting XX of 14 smoke compartments.

Finding include:

Observation on August 3, 2020, revealed the following:

a) 10:06 a.m., there was an unsecured fire extinguisher standing on the floor of the fourth floor penthouse 0401;
b) 11:10 a.m., there was a fire extinguisher obstructed by a printer station near room 263 on the second floor;
c) 1:25 p.m., there was a fire cabinet obstructed by a table in the CT Scan control room.

Interview with Facility staff on August 3, 2020, at 2:00 p.m., confirmed the portable for extinguisher deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in three instances, for three of more than 100 corridor doors inspected in the facility.

Findings include:

1. Observation on July 23, 2020, revealed the following corridor deficiencies:

a) 9:20 a.m., door #0006 to the transfer switch room in the basement failed to self close due to a damaged closer;
b) 9:30 a.m., the door to the kitchen near stairwell door #0027 in the basement failed to self close when tested.

Interview with the Facility Staff on August 3, 2020, at 2:00 p.m., confirmed the corridor door deficiencies.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in two instances, affecting four of 14 smoke compartments.

Findings include:

1. Observation on August 3, 2020, revealed the following smoke barrier door deficiencies:

a) 9:15 a.m., the door leading to building four from building three, in the basement, had unsealed penetrations;
b) 1:00 p.m., the doors separating building three and building four on the first floor, failed to function properly when tested.

Interview with the Facility Staff on august 3, 2020, at 2:00 p.m., confirmed the smoke barrier door deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain portable space heaters in one instance, affecting one out of fourteen smoke compartments.

Findings include:

1. Observation on August 3, 2020, at 12:55 p.m., revealed a portable space heater plugged into a power strip in the first floor emergency department, under the desk in the nurses station.

Interview with the Facility Staff on August 3, 2020, at 2:00 p.m., confirmed the portable space heater deficiency.

Based on observation and interview, it was determined the facility failed to maintain eight electrical receptacles for over 200 receptacles inspected.

Findings include:

1. Observation on August 3, 2020, revealed the following electrical outlets, within six feet of a sink, were not GFCI protected:

a) 10:52 a.m., in the short procedure nurse station at the stainless steel sink;
b) 10:54 a.m., kitchen in Dr. Popeye's office suite on the second floor;
c) 10:55 a.m., in the Hilliard Orthopedic nurse station;
d) 10:58 a.m., in the Hilliard Orthopedic exam room E;
e) 1:05 p.m., in the nuclear medicine rear work are;
f) 1:15 p.m., in the rear lab storage area;
g) 1:16 p.m., in the lab old brake room;
h) 1:17 p.m., in the lab specimen processing area.

Interview with the Facility Staff on August 5, 2020, at 2:00 p.m., confirmed the electrical receptacles deficiencies.

Based on documentation review and interview, it was determined that the facility failed to maintain the emergency generator in two instances, affecting the entire facility.

Findings include:

1. Documentation review on August 3, 2020, revealed the following:

a) 8:58 a.m., there was no documentation showing the completion of an annual load bank test. The facility was also unable to show that the emergency generator was achieving 30% load during monthly testing;
b) 9:00 a.m., there was no documentation showing the completion of a four hour run test within the last three years.

Interview with the Facility Staff on August 3, 2020, at 9:00 a.m., confirmed the lack of documentation available at the time of survey.