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Based on record review and staff interviews the facility failed to develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was four (4).

Findings include:

During the facility's emergency preparedness document review conducted on 11/06/19 between the hours of 9:30 a.m. and 11:00 a.m. the facility failed to complete the following emergency preparedness elements:

1. The emergency preparedness plan for the Critical Access Hospital (CAH) was not based on or included a documented, facility-based and community-based risk assessment.

2. The emergency preparedness plan did not address continuity of operations including delegation of authority and succession plans.

3. The emergency preparedness plan did not include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness official's efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and when applicable, of its participation in collaborative and cooperative planning efforts.

4. The emergency preparedness plan policies and procedures had not been reviewed and updated at least annually.

5. The emergency preparedness plan policies and procedures did not address the provision of subsistence needs for staff and patients whether they evacuate or shelter in place.

6. Policies and procedures for a system to track the location of on-duty staff and sheltered patients in the hospital's care during an emergency were not available for review.

7. Policies and procedures for safe evacuation from the hospital were not available for review.

8. Policies and procedures addressing a means to shelter in place for patients, staff and volunteers who remain in the critical access hospital were not available for review.

9. Policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information and secures and maintains availability of records were not available for review.

10. Policies and procedures for the use of volunteers during an emergency were not available for review.

11. The emergency preparedness plan did not contain proof of the development of arrangements with other CAHs or other providers to receive patients during cessation of operations.

12. Policies and procedures regarding the role of the CAH under a waiver declared by the secretary, in accordance with 1135 of the Act, in the provision of care and treatment at an alternate care site were not available for review.

13. The hospital had not developed a communication plan and the communication plan had not been reviewed and updated at least annually.

14. The communication plan did not include contact information for all of the following: staff, entities providing services under arrangement, patient's physicians, other CAHs and volunteers.

15. The communication plan did not include primary and alternate means of communication for the CAH staff and Federal, State, Tribal, Regional and local emergency management agencies.

16. The communication plan did include a method for sharing information and medical documentation for patients under the CAH's care, as necessary, with other health providers to maintain the continuity of care.

17. The communication plan did not include a means of providing information about the CAH's occupancy, needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center or designee.

18. The CAH did not conduct exercises to test the emergency plan at least annually as the facility did not participate in a full-scale community-based exercise or an additional exercise for the previous twelve (12) months.

19. In an interview on 11/06/19 at approximately 11:02 a.m. the Director of Nursing verified these findings. The findings were also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.

Based on record review and staff interviews the facility failed to ensure that required emergency lighting systems were tested in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was four (4).

Findings include:

1. Record review on 11/05/19 at approximately 1:00 p.m. revealed no documentation that battery powered emergency lights and battery powered exit lights located throughout the Outpatient Specialty Clinic had received monthly functional testing for a minimum of thirty (30) seconds for the previous twelve (12) months.

2. Record review on 11/05/19 at approximately 1:02 p.m. revealed no documentation that battery powered emergency lights and battery powered exit lights located throughout the Outpatient Specialty Clinic had received annual functional testing for a minimum of one and one half (1.5) hours for the previous twelve (12) months.

3. In an interview on 11/05/19 at approximately 1:04 p.m. the Support Services Manager verified these findings. The findings were also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.

Based on record review and staff interviews the facility failed to ensure that cooking equipment was protected in accordance with NFPA (National Fire Protection Association) 96. This deficient practice could affect all residents, staff, and visitors in the areas referenced. The facility's census was four (4).

Findings include:

1. Record review on 11/05/19 at approximately 8:43 a.m. revealed no documentation that the kitchen range hood had been cleaned on a semi-annual basis as the most current cleaning was completed in September of 2018.

2. In an interview on 11/05/19 at approximately 8:45 a.m. the Support Services Manager verified this finding. The finding was also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.

Based on record review and staff interviews the facility failed to ensure that air-conditioning, heating, ventilating ductwork and related equipment shall be in accordance with National Fire Protection Association (NFPA) 90A. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was four (4).

Findings include:

1. Record review on 11/04/19 at approximately 2:57 p.m. revealed no documentation for the testing of fire dampers located throughout the building for the previous six (6) years was provided during survey.

2. In an interview on 11/04/19 at approximately 2:59 p.m. the Support Services Manager verified this finding. The finding was also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.

Based on record review and staff interviews the facility failed to ensure that maintenance and testing of the generator and transfer switches was performed in accordance with National Fire Protection Association (NFPA) 110. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was four (4).

Findings include:

1. Record review on 11/05/19 at approximately 12:46 p.m. revealed no documentation of annual fuel quality testing for the emergency generator.

2. In an interview on 11/05/19 at approximately 12:48 p.m. the Support Services Manager verified this finding. The findings were also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.