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Based on observation, record review, and interview, the facility failed to incorporate into their Emergency Preparedness Program (EP) the policy and procedures for subsistence needs for staff and patients. The program did not completely incorporate provisions for maintaining temperatures in the event of the loss of the local utility.

The findings include:

On 03/11/2020 while reviewing the facility EP, there was no documentation of the facilities ability to maintain temperatures in the event of the loss of the local utility. Concurrent with the review the Administrator & Maintenance Director advised that the building generator was not capable of running the air conditioner unit. There was no policy and procedure specific to this potential event.

Based on record review and interview, the facility failed to provide Emergency Preparedness Program (EP), policies and procedures for the patients, safe evacuation from the LTC facility, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance in the event of an emergency. This would leave the occupants without means of support and accommodation during the emergency event.

The findings include:

On 03/11/2020 while reviewing the facility EP, documentation provided reveled the facility did not have any up to date transportation contracts to address the needs of patients, staff and volunteers that would need to be evacuated from the facility in the event of an emergency. Concurrent with the review, the Administrator said that they had no current agreements for transportation.

Based on record review and interview, the facility failed to incorporate Emergency Preparedness Program (EP) policies and procedures for the preservation, protection, and transfer of patient records including the security and availability of those records. This in the event of an emergency including an emergency requiring an evacuation would leave caregivers without the information necessary to provide for the medical needs of the patient and would leave the patients personal health information vulnerable to unauthorized access.

The findings include:

On 03/11/2020 while reviewing the facility's EP, there was no plan for preserving patient information, confidentiality, and providing for the availability of records. Concurrent with the review, the Maintenance Director described the process that the facility would use but it was not part of the EP.

Based on record review and interview, the facility failed to provide Emergency Preparedness Program (EP), policies and procedures for arrangement with other Facilities, the development of arrangements with other LTC facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients in the event of an emergency. This would leave the occupants without means of support and accommodation during the emergency event.

The findings include:

On 03/11/2020 while reviewing the facility EP, documentation provided reveled the facility did not have any up to date arrangement with other Facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients in the event of an emergency. Concurrent with the review, the Administrator said that they had no current agreements with other facilities.

Based on record review and interview, the facility failed to incorporate Emergency Preparedness Program (EP) policies and procedures for the provision of care under an 1135 waiver. This in the event of an emergency including an emergency requiring an evacuation as well as intake of patients from other jurisdictions would leave caregivers without the ability to provide for the specialized medical needs of patients.

The findings include:

On 03/11/2020 while reviewing the facility's EP, 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. Concurrent with the review, the Administrator advised she was unaware that there was not a policy in the book.

Based on observation, record review, and interview, the facility failed to incorporate into their Emergency Preparedness Program (EP) the policy and procedures for subsistence needs for staff and patients. The program did not completely incorporate provisions for maintaining temperatures in the event of the loss of the local utility.

The findings include:

On 03/11/2020 while reviewing the facility EP, there was no documentation of the facilities ability to maintain temperatures in the event of the loss of the local utility. Concurrent with the review the Administrator & Maintenance Director advised that the building generator was not capable of running the air conditioner unit.

Based on observation and interview with the Maintenance Director, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments to become involved in a Fire/Smoke situation. This could allow fire, smoke and fire gasses to enter the compartment, which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency.

The findings include:

During the Fire & Life Safety tour of the facility with the Maintenance Director on 03/11/2020, it was observed that several Smoke doors were not closing properly:

1. Storage room in the kitchen being propped open with a 2x4 board
2. Storage room across from room #118, door closure needs to replaced

The Maintenance Director verified these findings at the times observed.
NFPA 101, (2012 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on observation and interview with the Maintenance Director, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which have not been fire stopped or smoke sealed per the requirements of NFPA 101(2012 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

The findings include:

During the Fire & Life Safety tour of the facility with the Maintenance Director on 03/11/2020, it was found that penetrations through the wall above the ceiling have not been fire stopped or smoke sealed. The following locations were observed to have penetrations:

1. Double doors next to room # 105, 5-pipe penetrations above the ceiling
2. Emergency room # 2, penetration around the fire alarm

All locations were not properly protected with the required fire caulk. The Maintenance Director verified these findings at the times observed.
According to NFPA 101(2012 edition) 8.4.4 & 8.4.4.1 and 19.3.7.6

Based on observation and interview with the Maintenance Director, the facility failed to maintain electrical equipment and wiring in accordance with NFPA 70 the National Electric Code (N.E.C.), and NFPA 99 Health Care Facilities Code and to provide a facility free from electrical hazards. Failure to maintain electrical devices, equipment, and wiring in accordance with the applicable standards can result in the hazards of electric shock, electrocution, energized equipment and fire resulting from electric sources.

The findings include:

During the Fire & Life Safety tour of the facility with the Maintenance Director on 03/11/2020 it was found that there was relocatable power taps (RPT's) and extension cords in use in:

1. X-ray office, relocatable power tap plugged into a relocatable power tap
2. Ultrasound office, extension cord in use
3. Respiratory office multi-plug outlet being used to run a fan 7 the cord was running through the door opening, so the door was closing on the cord

The Maintenance Director verified these findings at the times observed Multiple outlet connections shall comply with NFPA 99 (2012 edition) 10.2.3.6. And in accordance with their listing.