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Based on record review and interview, the facility failed to incorporate policies and procedures for the provision of care under a 1135 waiver. This in the event of an emergency including an emergency requiring an evacuation would leave caregivers without the ability to provide for the specialized medical needs of patients.

The findings included:

On 12/4/17, while reviewing the facility's emergency management plan, there was no policy and procedure that specifically addressed the duties of caregivers following the issuance of an 1135 waiver by the Secretary of Health and Human Services.

On 12/4/17 at 4:35 p.m., the Administrator described the process that the facility would use but said that the 1135 waiver was not specifically addressed in the emergency preparedness plan.

Based on interviews and review of facility records, the facility failed to test electrical equipment in accordance with NFPA 99 and maintain electrical equipment in accordance with manufacturer's specifications and with NFPA 70. Failure to maintain electrical equipment could result in the loss of power or the failure of the equipment to operate as designed. Failure to conduct these tests could result in loss of power to the facility, energized equipment fires or fires resulting from the devices failing to perform as designed. This could endanger the occupants of the building from electric shock hazards or the loss of power providing life support and life safety features of the facility.

The findings included:

On 12/4/17, while conducting records review, evidence of main and feeder circuit breaker inspection and exercising was not provided by facility maintenance staff.

On 12/4/17 at 9:45 a.m., the interim Director of Plant Operations said that testing had not been performed within the last year.

NFPA 99 (2012 edition) 6.4.4.1.2.1; NFPA 110 (2010 edition) 8.4.6.1

Based on records review and interview, the facility failed to provide evidence of generator maintenance and testing in accordance with NFPA 110 (2011 edition). The facility failed to provide documentation of the generator battery electrolyte and fuel quality testing which is required to assure the ability of the prime mover to start. Batteries not able to start the prime mover will result in a loss of power to the facility thus endangering the patients and occupants of the facility.

The findings included:

1. On 12/4/17, while conducting records review, evidence of testing of the generator battery electrolyte could not be produced.

On 12/4/17 at 10:12 a.m., the interim Director of Plant Operations said that he was unaware of the testing requirement.

NFPA 110 (2010 edition) 8.3.7

2. On 12/4/17, while conducting records review, evidence of testing of the generator fuel was not found.

On 12/4/17 at 10:15 a.m., the interim Director of Plant Operations said that he had just assumed the position and was not certain if the fuel samples had been taken and testing performed.

NFPA 110 (2010 edition) 8.3.8