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This report documents the findings of the Emergency Preparedness survey conducted September 11, 2018. The facility was found to need correction to be in substantial compliance with 42 CFR Part 482, Emergency Preparedness Requirements for Hospitals.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(b)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to develop and implement all supporting EP policies and procedures, based on their established and communicated plan.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(b)(1)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to provide a secure and stable patient environment in the event of an elongated emergency, to include: (a) heating systems, (i) food, water, medical, and pharmaceutical supplies, and/or (d) sewage and/or waste disposal capable of supporting the length of time the facility has chosen to shelter-in-place, as identified within the facility's EP plan.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(b)(2)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to provide a system to track the location of on-duty staff and sheltered patients in the facility's care during an elongated emergency.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(b)(8)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to define its role under a waiver declared by the Secretary, in accordance with section 1135 of the Stafford Act, in the provision of care and treatment at its facility, or an alternate care site, as identified by emergency management officials.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(c)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to produce policies and procedures supporting an effective communications plan that is reviewed and updated annually to include, but not be limited to, a written emergency communication plan that contains how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(c)(2)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to produce the required contact information to include, but not limited to, tribal, state, and federal EP supportive agencies within their established comprehensive EP Communications Plan.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(c)(3)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to properly define primary and secondary means of communication with federal, state, regional, and local emergency preparedness personnel within the EP plan.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(d)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to provide a documented EP Training and Testing policy and Program that is based on the established Emergency Plan.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(d)(1)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to document and communicate the necessary training and testing to include, but not limited to, (i) all new and existing staff, (ii) external sources providing services under agreement, and/or (iii) volunteers, consistent with their expected roles within the EP plan, based on defined all-hazards scenarios.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(d)(2)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, the facility failed to provide proper documentation of the following: Perform mandated exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. Testing requirements to include, but not limited to, a community-based full-scale exercise. If a community-based full-scale exercise is not available and documented, an individual facility-based exercise shall be performed based on an all-hazards approach.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482.73(e)).

Findings include, but are not limited to:
On 09/11/18, during record review between 1057 hours and 1301 hours, (e)(3) the facility failed to provide documentation outlining continuing fuel support for the diesel generator in the event of an elongated emergency.

Surveyor was accompanied by the Facility Administrator, Administrative Assistant, Safety Officer and Maintenance Director who acknowledged the existence of these findings.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Safety Officer that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm or fire sprinkler system. This resulted in the potential for smoke and fire to spread to other areas of the facility.

Findings include, but are not limited to:
1. On 9/11/18, at 1055 hours, there was a unapproved hold open device not connected to the fire alarm system located on the rated fire door separating the Administrative Office from an egress corridor.
2. On 9/11/18, at 1056 hours, there was a unapproved hold open device not connected to the fire alarm system located on the rated fire door separating the Maintenance office from an egress corridor.
3. On 9/11/18, at 1604 hours, there was a unapproved hold open device not connected to the fire alarm system located on the rated fire door separating the Medical Surgery Housekeeping Closet from an egress corridor.
4. On 9/11/18, at 1608 hours, there was a unapproved hold open device not connected to the fire alarm system located on the rated fire door separating the Nursing Breakroom Restroom door.

Surveyor was accompanied by the Maintenance Director and Safety Officer who acknowledged the existence of these findings.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Safety Officer that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies.

Findings include, but are not limited to:
1. On 9/11/18, at 1539 hours, a leaking sprinkler head was found in the Materials Management room.
2. On 9/11/18, at 1542 hours, a leaking sprinkler head was found in the Kitchen.
3. On 9/11/18, at 11546 hours, two (2) leaking sprinkler heads were found in the Business Office.
4. On 9/11/18, at 1554 hours, two (2) leaking sprinkler heads were found in the X-ray room.

Surveyor was accompanied by the Maintenance Director and Safety Officer who acknowledged the existence of these findings.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Safety Officer that the facility failed to maintain approved smoke barrier doors of the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments.

Findings include, but are not limited to:
1. On 9/11/18, at 1552 hours, a listed fire door was found to be missing separating the Dark Room from other portions of the building.
2. On 9/11/18, at 1610 hours, a listed fire door was found to be missing separating the Medication Room from other portions of the building.

Surveyor was accompanied by the Maintenance Director and Safety Officer who acknowledged the existence of these findings.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Safety Officer that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which stipulates a minimum of 90-minutes of illumination during a power outage affecting the entire facility. This resulted in the potential for panic and confusion for staff and patients during a power outage.

Findings include, but are not limited to:
On 9/11/18, during record review between 1302 hours and 1520 hours, the facility failed to produce documentation showing the required annual 90 minute testing of the battery powered emergency lights and exit signs for the facility.

Surveyor was accompanied by the Maintenance Director and Safety Officer who acknowledged the existence of these findings.