HospitalInspections.org

Based on document review and interview, the facility failed to comply with Federal, State and Local Emergency Preparedness requirements. These requirements include the establishment of a Comprehensive Emergency Preparedness Program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented an Emergency Preparedness Program.


During interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated (by the Administrator) that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and Local Emergency Preparedness Requirements. These requirements include the establishment of a comprehensive Emergency Preparedness Program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and Local Emergency Preparedness requirements. These requirements include the establishment of a Comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and Local Emergency Preparedness requirements. These requirements include the establishment of a Comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and Local Emergency Preparedness requirements. These requirements include the establishment of a Comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and Local Emergency Preparedness requirements. These requirements include the establishment of a Comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and Local Emergency Preparedness requirements. These requirements include the establishment of a Comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local emergency preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness Program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local emergency preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness Program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local emergency preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness Program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local emergency preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness Program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local emergency preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness Program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local emergency preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness Program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Administrator and Director of Maintenance at 3:30 PM on 6/13/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Administrator and Director of Maintenance at 3:32 PM on 6/13/2018, it was stated that they were still in the process of developing the plan and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on observation, document review and interview, the facility failed to maintain proper testing and proper documentation for the emergency lighting. Testing of the emergency light helps to ensure emergency lighting in emergency conditions. Failure of emergency lighting may endanger all of the occupants within the facility.

The findings include:


During the document review with the Director of Maintenance and maintenance staff on 6/11/2018 at 1:00 PM, it was found that there was a lack of proper documentation for testing of the emergency lights. The 7 months of documentation stated that the annual test was done for 90 sec. (not min.) and done every month along with the 30 sec. monthly test. There was not an itemized list of lights or their locations. Emergency lights must be tested for 30 sec. monthly and 90 min. annually. Documentation of the tests must be maintained.


During interview with Director of Maintenance and maintenance staff at 3:30 PM, it was stated that a proper check- list would be created with proper testing procedures. It was also stated that they would begin documenting the procedure immediately.


During facility tour with Maintenance staff on 6/12/2018 from 1:00 PM thru 3:30 PM, it was found that the emergency battery lights were not operational in the following locations:

1) Building 12 - Main Electrical room - dead battery
2) Building 13 - Main Electrical room - dead battery


During interview with Director of Maintenance and maintenance staff at 3:30 PM, it was confirmed by staff present at the time of the finding. It was also stated that a facility-wide inspection would take place immediately to ensure that all emergency lighting was operational.


NFPA 101- 7.9 and 19.2.9.1

Based on observations and staff interview, the facility failed to provide smoke detection systems provided in patient sleeping areas. Failure to provide smoke detection can result in failure to detect a fire early, causing a delay in response of staff, thereby endangering the patients, staff, and other building occupants.


The findings include:


On June 12, 2018 from 10:00 AM to 3:30 PM during tour of facility, it was observed throughout Buildings 36B, 36D, 7, 8, 9,10, 15 & 17 which were not provided with automatic fire sprinkler system protection, failed to provide smoke detection within the sleeping rooms open to the corridor. Smoke detection shall be provided within spaces, which are able to be open to the corridor.


During interview with the Administrator and Director of Maintenance on 6/13/2018 at 3:45 PM, it was stated that they were unaware of the requirement and that a plan would be put in place to correct the deficiency.

NFPA 101 (2012) 19.3.4.5.1

Based on document review and interview, it was found that the facility failed to maintain required inspections on the sprinkler system. Failure to maintain or have inspected the system could lead to a delay in the sprinkler system or failure in time of emergency, which could affect all persons in the facility.


The findings include:


During document review with maintenance staff on 6/13/2018 at 11:00 AM, it was found that the facility failed to have the 5-year internal obstruction inspection performed. This inspection is required once every 5 years along with all other routine inspections and maintenance requirements. Last inspection performed was 9/12/2012.


During interview with the Director of Maintenance at 12:30 PM on 6/12/2018, it was stated that they had overlooked the inspection and that it would be scheduled to be done immediately.


During document review with maintenance staff on 6/13/2018 at 11:10 AM, it was found that previous deficiencies found during quarterly inspections were not corrected. On Building 57, there was a failure with a pressure flow switch for the last 2 quarterly inspections (2/23/2018 & 5/11/2018) in which there was no documentation of correction.


During Interview with the Director of Maintenance at 12:35 PM on 6/12/2018, it was stated that it was overlooked and that corrections would be scheduled immediately.



NFPA 101 -19.3.5.39.7., 4.5.8
NFPA 25 - 14.2

Based on observations, document review and interview, the facility failed to conduct the annual inspection of fire doors according to NFPA 80. Fire doors help to contain hazardous conditions and the failure of these doors endanger all persons within the facility by allowing the passage of smoke, flames, noxious gases, etc. into adjoining compartments.


The findings include:


During the document review with the Director of Maintenance and maintenance staff on 6/11/2018 at 1:15 PM, it was found that there was a lack of documentation for the 11 point annual inspection for rated fire doors.


During interview with the Director of Maintenance on 6/11/2018 at 3:50 PM, it was stated that he was unsure of what was included in the new regulation. It was also stated that now that he knows what needs to be done, that it would be done immediately.


During the facility tour with maintenance staff on 6/12/2018 from 10:30 am thru 3:30 PM it was found that rated fire doors were found with deficiencies in the following locations:

1) Building 13 1st floor- Double doors leading from hallway into bldg. 13 - more than 1/8" gap;
2) Between bldgs 12 & 13 - Double doors exit egress (close to bldg 13) - missing hardware;
3) Double doors from bldg 12 to connecting hallway - large holes in door from hardware change;
4) Building 13 - 1 hr rated door next to laboratory in building - Door makes contact with floor as to not close when released from mag locks);
5) Building 36B Laundry Room 1 - door glazing was broken and crack extending from bottom of
Frame to mid-frame not maintaining the rating of the door.


During interview with the Director of Maintenance on 6/12/2018 at 3:50 PM, it was stated that the annual fire door inspection will take place and that all doors noted and newly found will be corrected.


NFPA 80 - 5.2.4.2
CMS S & C 17-38
NFPA 101 (2012) 4.5.7, 4.5.8, 4.6.12.1, 4.6.12.3, 4.6.12.4, 8.3, 8.3.3, 8.5.4.5, 19.3.6.3.16, 19.3.7.6, 19.7.6

Based on observations and interview, the facility failed to prohibit improper use of and/or unapproved space heaters from the facility. Space heaters are a hazard with heating elements which exceed 212 degrees F. Space heaters have been a root cause in many documented fires and can endanger everyone within the facility.


The findings include:


During facility tour with Maintenance staff on 6/12/2018 from 1:00 PM thru 3:30 PM, it was found that deficiencies involving space heaters were found in the following locations:

1) Building 12 - room 12 - wire coil type (above 212 degrees);
2) Building 12 - room 14 - wire coil type (above 212 degrees);
3) Building 12 - Dentistry office - wire coil type (above 212 degrees) plugged into surge protector (RPT).


During interview with Director of Maintenance and maintenance staff at 3:40 PM on 6/12/2018, it was stated that the facility tried to uphold space heater regulations, but that some staff still bring them in without having them approved by the Maintenance Department. It was also stated that a facility-wide inspection would happen to ensure compliance.


NFPA 101 - 19.7.8

Based on observation and interview, the facility failed to ensure proper electrical safety. Following electrical safety requirements helps to decrease the chance of injury, hazard or fire. Pharmaceutical equipment that dispenses medicine which are not plugged into emergency power would be inoperable during a power outage, affecting all patients who would be in need.


The findings include:


During the facility tour with maintenance staff on 11/28/2017 thru 11/30/2017, it was found that unsafe electrical conditions were found in the following locations:

1) Building 12 - 1 East Med Room 60 - Pyxis machine was not plugged into emergency power


During interview with maintenance staff and the Director of Maintenance at 4:00 PM on 6/12/2018, it was acknowledged by the accompanying maintenance staff that the noted deficiency was present. It was then stated by the Director of Maintenance that inspection and corrections would be made immediately (facility-wide of all Pyxis equipment) and that an in-service for involved staff will be implemented.


NFPA 101 - 19.5.1.1
NFPA 101 - 9.1.2
NFPA 99 - 3.2.1.2
NFPA 1 - 11.1.5
NFPA 70

Based on observations and interview, the facility failed to prohibit/limit the use of extension cords and relocatable power taps (RPT/surge protectors). The use of surge protectors and extension cords allow the possibility of overloading the wiring dedicated to the outlet which can cause a fire hazard. Electrical fires can start in the walls or attic where it can go undetected, giving the hazard time to spread without being identified, placing the entire facility at risk.

The findings include:


During the facility tour with the Maintenance staff from 1:00 PM thru 3:30 PM on 6/12/2018, it was found that multiple offices in Buildings 12 and 13 contained RPTs, which had microwaves and/or refrigerators plugged into them. RPTs may be used in non-patient care areas with the exception of use with equipment with a heating element or motor.


During interview with the Director of Maintenance and maintenance staff at 3:45 PM on 6/12/2018, it was stated that maintenance staff have tried to continually regulate the use of RPTs. It was also stated that a thorough in-service would take place to help all staff be aware of proper usage and that another facility wide inspection would take place.


NFPA 101 - 19.5.1.1
NFPA 101 - 9.1.2
NFPA 99 - 3.2.1.2
NFPA 1 - 11.1.5

Based on observations and staff interview, the facility failed to maintain storage of compressed gasses in accordance with NFPA 99, Standard for Health Care Facilities, which could result in injury or loss of patients, staff, or other building occupants.


The findings include:


On June 12, 2018 from 10:50 AM to 11:00 AM while on tour, at the Boiler Building exterior South wall, it was observed multiple compressed gas cylinders, of multiple sizes, freestanding and not secured from falling or tipping in proper holders. Bottles were inside a steel cage, but not provided with proper stays or chains and had cylinders stacked on top of each other. One H-sized cylinder was observed freestanding outside the steel cage with no stays or chains to prevent falling. The Maintenance Director, Maintenance Supervisor, and Plant Operator acknowledged the unsecured bottles at time of finding. Compressed gas cylinders shall be properly secured and protected.


NFPA 101 (2012) 4.5.7, 4.5.8, 4.6.12.1, 4.6.12.3, 4.6.12.4, 19.3.2.4, 19.7.6

NFPA 99 (2012) 5.1.3.5.12, 11.3.2.4, 11.3.2.6, 11.3.2.9, 11.3.3.2, 11.6.2.3(1-12)