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Based on staff interview and record review, the facility failed to develop and implement policy and procedures for the use of volunteers in an emergency.

Policies and procedures

The facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:

(6) The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Findings include:

On May 28, 2020 the surveyors, along with the facility Administrator and the Director of Maintenance reviewed the facility's Emergency Plan. The plan did not include policies and procedures to address the use of volunteers in an emergency or other staffing strategies, including the use of State and Federally designated health care professional during an emergency.

During the exit conference on May 28, 2020, the above finding was again acknowledged by the Administrator and the Director of Maintenance.

Failure to address the use of volunteers or other staffing strategies in an emergency could adversely impact resident care during an emergency.

Based on observation it was determined the facility failed to fill penetrations in the electrical room walls where conduits passed through.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

On May 28, 2020 the surveyor, accompanied by the Director of Maintenance observed unsealed penetrations in the smoke barriers in the following locations:

1. In the electrical room, multiple penetrations were noted where conduits passed through the walls.

During the exit conference on May 28, 2020 the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failing seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients i time of a fire.

Based on Observation it was determined the facility did not allow access to the main electrical equipment room electrical panels.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

On May 28, 2020 the surveyors accompanied by the Director of Maintenance observed paint buckets and other building supplies within three feet of the main electrical room electrical panels.

During the exit conference on May 28, 2020 the above findings were again acknowledged by the Administrator and Director of Maintenance.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.

Based on Observation it was determined the facility allowed the use of a multiple outlet adapters and power strips.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On May 28, 2020 the surveyors, accompanied by the Director of Maintenance, observed the following:

1. Daisy chained power strip in the Information Technology room.
2. Multi plug adaptors located in the pharmacy, activity office and lobby.

During the exit conference on May 28, 2020 the above findings were again acknowledged by the Administrator and the Director of Maintenance.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.