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Based on record review and interview, the hospital failed to ensure development, maintenance, and annual review of a facility-based community-based risk assessment using an all hazards approach as required.

Findings:

Record review of the emergency preparedness plan showed the facility did not annually maintain and review the facility-based and community-based risk assessments that utilized an all hazards approach. An annual risk assessment for the facility emergency preparedness plan did not exist for 2018.

On 07/02/19 at 11:17 am, the surveyor asked Staff K for written documentation of the facility's risk assessments and associated emergency preparedness strategies. Staff K stated the risk assessment had not been updated annually since 2016. The documentation did not exist. Staff K stated Mercy Watonga is in process of writing policies to ensure compliance with all E-tags. Mercy OKC appointed a Emergency Management Regional personnel and staff K will be assisted with development of this assessment.

Based on record review and interview, the hospital failed to develop policy for strategies addressing and identifying the patient/client population needs of at risk or vulnerable patient population during an emergency event or disaster.

Findings:

Record review of the emergency preparedness plan showed the facility did not develop or identify the facility's patient client populations that would be at risk; the type of services the facility has the ability to provide during an emergency event.


On 07/02/19 at 10:17 am, the surveyor asked Staff K if the facility identified and addressed the patient/client population needs of at risk and the types of services the facility would be able to provide in an emergency. The documentation did not exist. Staff K stated Mercy Watonga is in process of writing policies to ensure compliance with all E-tags. Mercy OKC appointed a Emergency Management Regional personnel and staff K will be assisted with development with the facilities policies and procedures. Staff K stated the facility is in the process of updating and revising the policies and procedures.

Based on record review and staff interview, the facility's Emergency Preparedness plan failed to address policies and procedures regarding the sheltering in place of residents, staff, and volunteers who remain in the facility during an emergency or disaster event. The facility lacked a policy.

Findings:

Record review of the facility's Emergency Preparedness plan revealed that they lacked a policy regarding the sheltering in place of residents, staff, and volunteers who will remain in the facility during an emergency.


On 07/02/19 at 2:00 pm, the surveyor informed Staff K the facilities are required to have policies and procedures for sheltering in place which align with the facility's risk assessment and are expected to include the criteria for determining which patients and staff would be sheltered in place. Staff K stated Mercy Watonga is in process of writing policies to ensure compliance with all E-tags. Mercy OKC appointed a Emergency Management Regional personnel and staff K will be assisted with development of sheltering in place policies and procedures. Staff K stated the facility is in the process of updating and revising the policies and procedures.

Based on record review and interview the facility failed to ensure policy and procedures were established to address the use of volunteers in an emergency.

Findings:

On 07/02/19 at 1:38 pm, the surveyor requested documentation to verify volunteers at the facility had been trained for disasters. The plant operations manager stated the facility did have a policy in place to address the medical volunteers roles and responsibilities to address the non-medical auxiliary volunteers. The policy did not exist. Staff K stated Mercy Watonga is in process of writing policies to ensure compliance with all E-tags. Mercy OKC appointed a Emergency Management Regional personnel and staff K will be assisted with development of volunteer policy and procedures.

Based on record review and interview the facility failed to ensure the development of written transfer agreements or contracted agreements with other facilities identified in their emergency procedure manual to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Findings:

On 07/02/19 at 1:17 pm, the surveyor asked Staff K for documentation of transfer agreement or contracted arrangements to receive patients in the event of an disaster and the facility would not be able to shelter in place. Staff K stated the facility is working on written transfer agreement's with other facilities. The documentation did not exist.

Based on record review and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with section 1135 of the act in provision of care and treatment. The facility lacked a policy.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster.


On 07/02/19 at 10:50 am, the surveyor asked Staff K if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff K stated the Mercy Watonga is in process of writing policies to ensure compliance with all E-tags. Mercy OKC appointed a Emergency Management Regional individual and staff K will be assisted with development of the 1135 waiver policy. The document did not exist.

Record review of the facility emergency preparedness communication plan did not contain methods for sharing information and medical documentation for patients under the facility's care with other health care providers to maintain continuity of care in the event of an evacuation as required.

On 07/02/19 at 1:33 pm, the surveyor asked Staff K for documentation to verify the facility had developed an emergency preparedness communication plan which included how the facility would share information for patients under the facility's care as necessary with other health care providers in the event of an emergency. Staff K stated the facility would develop a plan to address sharing information in the event of an evacuation as permitted under 45 CFR 164.510(b)(4). Staff K stated Mercy Watonga is in process of writing policies to ensure compliance with all E-tags. Mercy OKC appointed a Emergency Management Regional personnel and staff K will be assisted with development of this policy and procedures.

Based on record review and interview, the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the fire drills did not document a transmission of a fire alarm signal.

On 07/02/19 at 2:18 pm the surveyor requested fire drills from the facility.

On 07/02/19 at 2:20 pm, the surveyor asked staff K to show where the documentation of the transmission of a fire alarm signal was received from the alarm company or fire department. Staff K stated the facility did call before the fire drills but did not document. Staff K stated the transmission of fire alarm signal will be added to the form.

Based on record review and interview, the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the fire rated door assembly inspections for 2017-2018 were not completed and the documentation did not exist.

On 07/02/19 at 01:35 pm, the surveyor asked Staff K for the fire rated door assembly inspections. Staff K stated, the inspection was not completed for 2017-2018. The facility was unaware of this requirement.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed.

On 07/02/19 at 9:30 am during the entrance conference, the surveyor asked Staff K for the EES and Medical Gas building system risk assessments, Staff K stated he had not completed the medical gas or EES building system risk assessments he was unaware of the requirement. The documentation did not exist.

Based on record review and interview the facility failed to ensure hospital grade electrical receptacles in patient care areas were tested after initial installation, and testing was performed at intervals defined by documented performance data as required.

Findings:

Record review showed the facility had not tested hospital grade electrical receptacles in patient care areas after the receptacles had been replaced, and the testing was not performed at designated intervals defined by their documented performance data. The electrical receptacle impedance testing documentation did not exist.

On 07/02/19 at 1:45 pm the surveyor asked Staff K for patient care area electrical receptacle impedance testing/inspections. Staff K stated he was in the process of completing the testing.