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Based on the number of Emergency Preparedness findings from record review and staff interview it was determined the facility failed to meet the Condition of Participation for establishing and maintaining a comprehensive emergency preparedness program that complies with all applicable Federal, State and local emergency preparedness requirements. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 24.

Findings include:

1. During the facility emergency preparedness document review conducted on 01/29/18 between the hours of 1:00 p.m. and 4:00 p.m. it was determined the facility failed to complete the following emergency preparedness elements:

a. Policies and procedures addressing the subsistence needs of staff and patients were not available for review.

b. Policies and procedures for tracking of staff and patients were not available for review.

c. Policies and procedures for safe evacuation from the hospital including consideration of care and treatment needs of evacuees: staff responsibilities; transportation; identification of evacuation location(s) were not available for review.

d. Policies and procedures for Medical Documentation were not available for review.

e. Policies and procedures for volunteers was not available for review.

f. Development of arrangements with other facilities was not available for review.

g. Policies and procedures for roles under a Waiver declared by Secretary were not available for review.

h. Policies and procedures for names and contact information for staff, entities providing services under agreement, patients, physicians, other hospitals and volunteers were not available for review.

i. Contact information for emergency officials was not available for review.

j. Primary and alternate means for communication plans were not available for review.

k. Policies and procedures for sharing information on occupancy needs were not available for review.

2. The above findings were verified with the Facilities Manager at the time of discovery and again with the Administrator at the time of exit.

Based on observation and staff interview it was determined the facility failed to ensure the building was protected throughout by an approved automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 24.

Findings include:

1. An observation on 01/30/18 at approximately 3:30 p.m. revealed a sprinkler head in the Kitchen Dish Machine Room which was located approximately eleven (11) inches away from a light fixture and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

2. An observation on 01/30/18 at approximately 3:33 p.m. revealed a sprinkler head in the Kitchen Dish Machine Room which was located approximately nine (9) inches away from a light fixture and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

3. The above findings were verified with the Facilities Manager at the time of discovery and again with the Administrator at the time of exit.

Based on observation and staff interview it was determined the facility failed to ensure smoke barriers were constructed and maintained to the appropriate fire resistance rating in accordance with National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 24.

Findings include:

1. An observation on 01/30/18 at approximately 2:46 p.m. revealed a penetration (approximately 2 inches by 15 inches) in the 1st Floor smoke barrier in the interstitial space above the corridor doors near the Chapel.

2. An observation on 01/30/18 at approximately 2:50 p.m. revealed a penetration (approximately 2 feet by 3 feet) in the 1st Floor smoke barrier in the interstitial space above the corridor doors near the Chapel.

3. An observation on 01/30/18 at approximately 2:53 p.m. revealed a penetration (approximately 3 feet by 3 feet) in the 1st Floor smoke barrier in the interstitial space above the corridor running towards the Elevators near the Chapel.

4. The above findings were verified with the Facilities Manager at the time of discovery and again with the Administrator at the time of exit.

Based on observation, record review and staff interview it was determined the facility failed to ensure air-conditioning, heating, ventilating ductwork and related equipment shall be in accordance with National Fire Protection Association (NFPA) 90A. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 24.

Findings include:

1. Observation on 01/30/18 at approximately 11:27 a.m. revealed a damper in the 3rd floor smoke barrier near Room 318 of the Echo Suite, which had not been tested as required.

2. Observation on 01/30/18 at approximately 11:38 a.m. revealed a damper in the 3rd floor smoke barrier above the Education Room towards the corridor, which had not been tested as required.

3. Observation on 01/30/18 at approximately 11:57 a.m. revealed a damper in the 3rd floor smoke barrier near the Direct Support Services Office, which had not been tested as required.

4. Observation on 01/30/18 at approximately 12:06 p.m. revealed a damper in the 3rd floor mechanical room fire barrier for air handling unit #5, which had not been tested as required.

5. Observation on 01/30/18 at approximately 1:12 p.m. revealed three (3) dampers in the 2nd floor smoke barrier near OBS1, which had not been tested as required.

6. Observation on 01/30/18 at approximately 1:37 p.m. revealed a smoke damper in the 2nd floor smoke barrier above the IT Closet in the 2nd floor waiting area, towards the OBS1 corridor, which had not been tested as required.

7. Observation on 01/30/18 at approximately 1:52 p.m. revealed five (5) dampers in the 2nd floor smoke barrier near the Special Care Unit entrance, which had not been tested as required.

8. Observation on 01/30/18 at approximately 2:16 p.m. revealed two (2) dampers in the 2nd floor smoke barrier near the OB Physicians and Residents Lounge, which had not been tested as required.

9. The above findings were verified with the Facilities Manager at the time of discovery and again with the Administrator at the time of exit.

Based on record review and staff interview it was determined the facility failed to ensure periodic testing and inspection of elevators in accordance with National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 24.

Findings include:

1. Record review on 01/31/18 at 9:13 a.m. revealed there was no documentation the Firefighter's Service for the elevators had been operated monthly.

2. The above finding was verified with the Facilities Manager at the time of discovery and again with the Administrator at the time of exit.

Based on record review and staff interview it was determined the facility failed to ensure maintenance and testing of the generator and transfer switches was performed in accordance with National Fire Protection Association (NFPA) 110. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 24.

Findings include:

1. Record review on 01/29/18 at approximately 11:43 a.m. revealed there was no documentation of monthly testing and recording of electrolyte specific gravity or battery conductance testing for each cell of the batteries of the emergency generators serving the facility.

2. The above finding was verified with the Facilities Manager at the time of discovery and again with the Administrator at the time of exit.

Based on record review and staff interview it was determined the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care related equipment in accordance with National Fire Protection Association (NFPA) 99. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 24.

Findings include:

1. Record review on 01/31/18 at approximately 10:15 a.m. revealed there was no documentation of electrical resistance, current leakage, or touch current testing for medical equipment that is serviced by in-house medical equipment staff.

2. The above finding was verified with the Facilities Manager at the time of discovery and again with the Administrator at the time of exit.