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Based on record review, and interview, the facility failed to incorporate into their Emergency Preparedness Program (EP) the policy and procedures for subsistence needs for staff and patients. The program did not completely incorporate provisions for maintaining temperatures in the event of the loss of the local utility.

Findings included:

During review of the facility records with Director of Plant Operations and the Assistant Director of Plant Operations on 07/18/2019 between 11:45a.m. and 12:45p.m., the facility failed to provide evidence that they were not able to monitor temperatures in the affected areas. In an interview conducted with the Assistant Chief Nursing Officer, they said that temperatures were not monitored during the time of loss of the public utility.

Based on record review and interview, with the Director of Plant Operations, the facility failed to maintain the transfer switch gear.

Findings included:

During facility record review with the Director of Plant Operations, it was revealed that during the scheduled maintenance by the facility's vendor on 09/05/2018, it was documented that transfer switch ATS-EQB control panel had been recommended to be replaced in the near future. It was also documented that transfer switch ATS-9(EA) caused major damage to equipment years ago when bypassed and had never been repaired. An interview was conducted with the Director of Plant Operations concurrent with observations and confirmed the findings.

per NFPA 101 (2012 Edition) 4.5.8
per NFPA 99 (2012 Edition) 6.4.4.1.1.3
per NFPA 110 (2010 Edition) 8.3.5