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Based on record review, the facility failed to include policies and procedures for the 1135 waiver in the emergency preparedness program.

The finding included:

Record review on 08/05/19 at 10:20 AM, the facility could not provide polices and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

The Emergency Preparedness director was present when finding was verified and the administrator acknowledged the deficiency during the exit conference on 08/05/19.

Based on records review, the facility failed to conduct all required fire drills.

The findings included:

During the records review on 08/05/19 at 9:54 AM, the facility failed to provide fire drills for the following shifts and quarters.
a. a 3rd shift fire drill for the 2nd quarter of 2019.

b. a 2nd shift fire drill for the 1st quarter of 2019.

c. a 3rd shift fire drill for the 4th quarter of 2018.

d. a 3rd shift fire drill for the 3rd quarter of 2018.
National Fire Protection Association (NFPA) 101, 19.7.1.6 (2012 Ed.)


The manager was present during the findings and the administrator acknowledged the deficiencies during the exit conference on 08/05/19.

Based on records review, the facility failed to inspect fire door assemblies.

The findings included:

During the records review on 08/05/19 at 10:00 AM, the facility could not provide documentation of an annual inspection and testing of the fire door assemblies.
NFPA 101, 19.7.6 (2012 Ed.)
NFPA 101, 8.3.3.1 (2012 Ed.)
NFPA 80, 5.2.1 (2010 Ed.)
NFPA 80, 5.2.3 (2010 Ed.)

The Dir. of Engineering acknowledged the deficiency during the records review and the administrator acknowledged the deficiency during the exit conference on 08/05/19.