HospitalInspections.org

Based on document review and interview, the facility failed to comply with Federal, State and local Emergency Preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Director of Maintenance at 2:30 PM on 3/1/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Director of Maintenance at 3:00 PM on 2/27/2018, it was stated that they were still in the process of developing the plan at the corporate level and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local Emergency Preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Director of Maintenance at 2:30 PM on 3/1/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Director of Maintenance at 3:00 PM on 2/27/2018, it was stated that they were still in the process of developing the plan at the corporate level and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local Emergency Preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Director of Maintenance at 2:30 PM on 3/1/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Director of Maintenance at 3:00 PM on 2/27/2018, it was stated that they were still in the process of developing the plan on the corporate level and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local Emergency Preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Director of Maintenance at 2:30 PM on 3/1/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Director of Maintenance at 3:00 PM on 2/27/2018, it was stated that they were still in the process of developing the plan at the corporate level and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local Emergency Preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Director of Maintenance at 2:30 PM on 3/1/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During the interview with the Director of Maintenance at 3:00 PM on 2/27/2018, it was stated that they were still in the process of developing the plan on the corporate level and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.

CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local Emergency Preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Director of Maintenance at 2:30 PM on 3/1/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During an interview with the Director of Maintenance at 3:00 PM on 2/27/2018, it was stated that they were still in the process of developing the plan at the corporate level and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local Emergency Preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Director of Maintenance at 2:30 PM on 3/1/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During an interview with the Director of Maintenance at 3:00 PM on 2/27/2018, it was stated that they were still in the process of developing the plan on the corporate level, and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on document review and interview, the facility failed to comply with Federal, State and local Emergency Preparedness requirements. These requirements include the establishment of a comprehensive Emergency Preparedness program. This program helps to ensure proper actions, knowledge and training in hazardous situations.


The findings include:


During document review with the Director of Maintenance at 2:30 PM on 3/1/2018, it was found that there was no documentation identifying that the facility had established or implemented emergency preparedness policies/procedures/plans that satisfy this section of the Emergency Preparedness Plan.


During an interview with the Director of Maintenance at 3:00 PM on 2/27/2018, it was stated that they were still in the process of developing the plan on the corporate level and that the facility would continue to develop the plan so that it may be implemented as quickly as possible.


CMS - S&C 17-29-ALL
Federal Register Vol. 81, No. 180

Based on documentation review and interview, the facility failed to conduct the annual inspection of fire doors according to NFPA 80. Fire doors help to contain hazardous conditions and the failure of these doors endangers all persons within the facility by allowing the passage of smoke, flames, noxious gases, etc. into adjoining compartments.


The findings include:


During document review with the Director of Maintenance on 3/1/2018 at 10:15 AM, it was found that there was a lack of documentation for the 11 point annual inspection for fire doors. It was noted that there was documentation for functionality (closing and latching) of the doors present, but not for inspection of the other listed items.


During interview with the Director of Maintenance on 3/1/2018 at 10:18 AM, it was stated that he was unsure of what was included in the new regulation. It was also stated that now that he knows what needs to be done, that it would be done immediately.


NFPA 80 - 5.2.4.2
CMS S & C 17-38

Based on record review and staff interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72, maintaining the integrity of the system to alarm in the event of a fire to allow for the emergency egress and relocation of patients, staff, or other building occupants, which could result in injury or loss.


The findings include:


During record review on 3/1/2018 at 11:30 AM, the Fire Alarm testing records showed that according to the documentation, not all devices had been tested, inspected, and maintained to ensure the integrity of the fire alarm system in accordance with NFPA 72. Duct Detector devices were missed and not marked on inspection documents as being verified for sensitivity, nor verified utilizing sampling tubes for the correct pressure differential (within the manufacturer's published ranges) between the inlet and exhaust tubes using a method acceptable to the manufacturer to ensure that the device will properly sample the airstream.


During interview with the Maintenance Director at time of finding, it was acknowledged that there were no records to show that the duct detector devices of the facility had been verified as within the sensitivity manufacture range and for differential pressure.


NFPA 72 (2010) 14.1, 14.1.1, 14.2.1.1, 14.2.1.2, 14.2.6.2, 14.4.2.2, Table 14.4.2.2(14)(g)(6), 14.4.5, Table 14.4.5.

NFPA 101 (2012) 9.6, 9.6.1.5, 19.3.4.1

NFPA 72 (2013) 14.1, 14.1.1, 14.2.1.1, 14.2.1.2, 14.2.6.2, 14.4.2.2, Table 14.4.2.2(14)(g)(6), 14.4.5, Table 14.4.5.

NFPA 101 (2015) 9.6, 9.6.1.5, 19.3.4.1