HospitalInspections.org

Based on record review and interview, the facility failed to develop an emergency preparedness program in accordance with 42 CFR 482.15 that includes the following elements:
a) An Emergency Plan
b) Policies and Procedures
c) A Communication Plan
d) Training and Testing
e) An Emergency and Standby Power System
This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Operating Officer on 06/26/18 from 1:01 p.m. to 2:38 p.m., the facility had an emergency preparedness document, but it was incomplete. The documentation that was given over for review was entitled "Emergency Management Plan" and consisted of several policies and procedures. It did not contain an all hazards approach or a facility based all hazard approach. Based on interview at the time of record review, the Chief Operating Officer acknowledged that the facility emergency preparedness program lacked all the above listed items. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually in accordance with 42 CFR 482.15(a). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Operating Officer on 06/26/18 from 1:01 p.m. to 2:38 p.m., the facility had an emergency preparedness document, but it was incomplete. The facility failed to develop and maintain an emergency preparedness plan using an all hazards approach that identified in advance essential functions that was reviewed and updated at least annually. Based on interview at the time of record review, the Chief Operating Officer acknowledged the emergency preparedness plan lacked an all hazards approach and was not reviewed or updated at least annually. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and implement emergency preparedness policies and procedures. The policies and procedures must be reviewed and updated at least annually in accordance with 42 CFR 482.15(b). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Operating Officer on 06/26/18 from 1:01 p.m. to 2:38 p.m., the facility had an emergency preparedness document, but it was incomplete. The facility failed to develop and implement emergency preparedness policies and procedures. The policies and procedures must be reviewed and updated at least annually. Based on interview at the time of record review, the Chief Operating Officer acknowledged the emergency preparedness plan failed to develop and implement policies and procedures that were reviewed or updated at least annually. On 06/26/2018 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws was reviewed and updated at least annually in accordance with 42 CFR 482.15(c). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Operating Officer on 06/26/18 from 1:01 p.m. to 2:38 p.m., the facility had an emergency preparedness document, but it was incomplete. The facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws was reviewed and updated at least annually. Based on interview at the time of record review, the facility Chief Operating Officer acknowledged the facility emergency preparedness plan failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws was reviewed and updated at least annually. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least annually in accordance with 42 CFR 482.15(d). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Operating Officer on 06/26/18 from 1:01 p.m. to 2:38 p.m., the facility had an emergency preparedness document, but it was incomplete. The facility failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least annually. Based on interview at the time of record review, the facility Chief Operating Officer acknowledged that the facility failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least annually. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code in accordance with 42 CFR 482.15(e)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review on 06/26/18 at 10:19 a.m. of the generator load testing documentation with the Chief Operating Officer, the load information to show the actual load percentage for the diesel powered generator was not documented. Based on interview at the time of record review, the Chief Operating Officer acknowledged the generator ran under load on a weekly basis but he could not provide documentation to show the generator could achieve 30 % of the name plate rating. Additionally, the Plant Operations Manager acknowledged a load bank test for the generator may have occurred within the past year, but the documentation could not be provided at the time of this survey. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on observation and interview, the facility failed to ensure 5 of over 45 door within the facility were provided with door latches that required only one operation to open. LSC 19.2.2.1 states doors complying with 7.2.1 shall be permitted. 7.2.1.5.10.2 requires the releasing mechanism shall open the door leaf with not more than one releasing operation. This deficient practice could affect as many as 5 patients, 2 staff and visitors within the facility.

Findings include:

Based on observation on 06/26/18 between 11:18 a.m. and 12:55 p.m. with the Chief Operating Officer, the following was noted:
1) The door mechanism to the second floor Records Clerks office had two operating mechanisms on it, a door handle and a deadbolt lock.
2) The door mechanism to the second floor Recreation room had two operating mechanisms on it, a door handle and a deadbolt lock.
3) The door mechanism to the second floor Conference room had two operating mechanisms on it, a door handle and a deadbolt lock.
4) The door mechanism to the second floor Group room had two operating mechanisms on it, a door handle and a deadbolt lock.
5) The door mechanism to the second floor Inpatient unit Clinical staff office had two operating mechanisms on it, a door handle and a deadbolt lock.
Based on interview at the time of observations, Chief Operating Officer acknowledged all the above listed doors having an independent dead bolt as well as a door handle with a latching mechanism. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, 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.

Findings include:

Based on record review on 06/26/18 between 9:20 a.m. and 11:16 a.m. with the Chief Operating Officer, the facility had a fire watch plan entitled "Fire Watch", but it was incomplete. The plan states " ...fire watch rounds will be continuous and will be done at intervals by an individual with no other job duties." It does not however state that the person conducting the fire watch shall be a trained person. Based on interview at the time of record review, the facility Chief Operating Officer acknowledged the fire watch documentation provided did not state anything about the individual doing the fire watch as having to be a trained individual. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review, and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 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 water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients and staff in the facility.

Findings include:

Based on review of Certified Fire System Consultant's "Inspection Form / Wet & Dry Pipe Sprinkler" documentation dated 06/11/18, 03/05/18, 12/19/17, and 09/14/17, there were documented sprinkler gauge and control valve inspections noted. When asked for the monthly control valve and gauge inspection documentation for the facility sprinkler system, no documentation could be provided for review. Based on interview at the time of record review, the Chief Operating Officer acknowledged monthly sprinkler system gauge and control valve inspections for the last twelve months was not available for review. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed for the protection of 15 of 15 patients in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observation on 06/26/18 between 9:20 a.m. and 11:16 a.m. with the Chief Operating Officer, the facility had a fire watch plan entitled "Fire Watch", but it was incomplete. The plan states " ...fire watch rounds will be continuous and will be done at intervals by an individual with no other job duties." It does not however state that the person conducting the fire watch shall be a trained person. Based on interview at the time of record review, the facility Chief Operating Officer acknowledged the fire watch documentation provided did not state anything about the individual doing the fire watch had to be a trained individual, or have proper training. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on observation and interview, the facility failed to ensure 4 of 18 sets of patient room doors to the corridor would close and latch into the door frame. This deficient practice could affect approximately 4 patients, as well as staff and visitors.

Findings include:

Based on observation on 06/26/18 between 10:18 a.m. and 12:55 p.m. with the Chief Operating Officer, the following was noted:
1) Patient room # 278 failed to close and automatically latch into the frame because the only latching device on the door was a dead bolt type latching system that operated with a key
2) Patient room # 280 failed to close and automatically latch into the frame because the only latching device on the door was a dead bolt type latching system that operated with a key
3) Patient room # 282 failed to close and automatically latch into the frame because the only latching device on the door was a dead bolt type latching system that operated with a key
4) Patient room # 284 failed to close and automatically latch into the frame because the only latching device on the door was a dead bolt type latching system that operated with a key
Based on interview at the time of observations, Chief Operating Officer acknowledged all the above listed doors having only a dead bolt as the doors only latching mechanism. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected and varied times for 7 of the last 12 months. This deficient practice affects all occupants.

Findings include:

Based on record review on 06/26/18 between 9:20 a.m. and 11:16 a.m. of the "Fire Drill Report" form with the Chief Operating Officer, four of the four sequential second shift fire drills took place between 7:11 p.m. and 7:34 p.m. for four of the last four quarters. (First quarter drill was done at 7:30 p.m. / Second quarter drill was done at 7:34 p.m. / Third quarter drill was done at 7:11 p.m. / Fourth quarter drill was done at 7:32 p.m.) Then again, three sequential third shift fire drills took place between 5:20 a.m. and 5:30 a.m. for three of the last four quarters. (First quarter drill was done at 5:20 a.m. / Second quarter drill was done at 5:30 a.m. / Third quarter drill was done at 5:30 a.m.) Based on interview at the time of record review, the Chief Operating Officer acknowledged the fire drills were not varied by at least two hours. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to exercise the generator annually to meet the requirements of NFPA 110, 2010 Edition, the Standard for Emergency and Standby Powers Systems, Chapter 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS (Emergency Power Supply) nameplate kW rating.
Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS (Emergency Power Supply System) load and shall be exercised annually with supplemental loads (Load Bank Test) at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. This deficient practice could affect all occupants.

Findings include:

Based on record review on 06/26/18 at 10:19 a.m. of the generator load testing documentation with the Chief Operating Officer, the load information to show the actual load percentage for the diesel powered generator was not documented. Based on interview at the time of record review, the Chief Operating Officer acknowledged the generator ran under load on a weekly basis but he could not provide documentation to show the generator could achieve 30 % of the name plate rating. Additionally, the Plant Operations Manager acknowledged a load bank test for the generator may have occurred within the past year, but the documentation could not be provided at the time of this survey. On 06/26/18 at 2:57 p.m., during the exit conference with the facility Chief Operating Officer, the Director of Security, and the Chief Executive Officer, no additional information or evidence could be provided contrary to this deficient finding.