The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

JACKSON MEMORIAL HOSPITAL 1611 NW 12TH AVE MIAMI, FL 33136 Jan. 28, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based upon record review and interview it was determined Jackson Memorial South Hospital was not providing Medicare patients with the Important Message from Medicare as required for 7 of 7 Medicare recipient medical records reviewed (#63, 64, 66, 67, 80, 82, and 87) on 1/25/11.

Findings include:

During record review on 1/25/11 a surveyor could not locate the Important Message notice which Medicare recipients are to receive upon admission to the hospital for patients 63, 64, 66, and 67.

The surveyor met with the Admissions Co-coordinator (AC) for the South campus and the Quality Assurance Co-coordinator (QAPI) for the South campus on 1/25/11 at 11:46 a.m. to discuss where the Important Message from Medicare could be located. The AC stated Jackson Main campus had instructed them they do not need to present the Important Message from Medicare on Admission. The facility only needs to use the forms in the Admission/Registration kit. The kit includes 1) Medicare Payment Authorization & Exclusion explanation; 2) How to request a review of the notice of non coverage and 3) Medicare Authorization, Release and Assignment, and Agreement to Pay.

The surveyor was informed the facility stopped using the Important Message from Medicare at the time of admission when the facility went to the computerized medical records system "Cerner" in May 2008.

At 1:20 p.m. on 1/25/11 the QAPI Coordinator informed the surveyor the issue of the Important Message notice from Medicare had come up at the Jackson Main campus and Jackson South would resume utilizing this document in their Admission kit.

During a team meeting on 1/25/11 at 3:30 p.m. the surveyor determined team members also did not have the Important Message from Medicare in the records of patients 80, 82, and 87.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations, interviews and record reviews, the facility failed to assure the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured.


The findings include:

1. The facility failed to ensure that prohibited space heaters were in use, and to follow the facility policy regarding space heaters. Space heaters with elements which exceed 212 degrees Fahrenheit are prohibited in health care facilities.
Please refer to K-0070 for additional information

2. The facility, it was determined that the facility failed to ensure that non-medical flammable medical gas is handled and stored in accordance with NFPA 99. Unsecured oxygen cylinders have the potential if knocked over can rupture at the neck of the cylinder causing a super oxygen enriched atmosphere, increasing the flammability of all surrounding building contents, and the cylinder itself becoming projectile endangering all building occupants.

Please refer to K-0076 for additional information

3. During tour of the facility, it was determined that the facility failed to ensure that medical gas is handled and stored in accordance with NFPA 99.

Please refer to K-0077 for additional information

4. During tour of the facility, interviews with the staff, and a review of the facility records, conducted during the survey of Jackson Health System, it was determined that the facility failed to maintain the fire/smoke dampers in reliable operating condition. This condition could place the lives of the occupants in smoke environment should a fire occur and the fire/smoke dampers failed to respond.

Please refer to K-0104 for additional information


5. During tour of the facility, and interviews with facility staff, the facility failed to adequately protect the building occupants from flammable and combustible liquids. The facility further failed to maintain fire protection and occupancy features necessary to minimize danger to life in accordance with NFPA 101-19.3.2, 10.3.5., and the NFPA 30 (Flammable Liquid Code).

Please refer to K-0135 for additional information

6. The facility records, and interview with the staff during the Fire Life Safety survey, it was determined that the facility failed to ensure that all electrical wiring and electrical equipment are properly installed, tested as frequently as required, and maintained in reliable operating condition, tested as frequently as required, and maintained in accordance with NFPA 101, and NFPA 70.

Please refer to K-0147 for additional information
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, staff and patient interviews and records reviewed, the facility failed to honor patient right to personal privacy for making phone calls.

The findings include:

1. On 1/25/11 at 10:00 a.m. an initial tour of the children's unit was conducted. Observation of the unit showed there was no phone hanging on the wall like the other units toured. At this time the director of patient care services stated the phones for the children to use are at the nurses station and the staff will dial the phone numbers for them. The staff want to monitor who the children are calling.

Observation at 11:45 a.m. on 1/26/11 in the children's unit showed a posting of patient rights. One of these rights is to have private communications including telephone use. At 11:50 a.m. an interview was conducted with the unit secretary concerning the use of the telephone for the children. She stated when the patient wants to use the phone they come to the window at the nurse's station and ask to use the phone. The unit secretary dials the phone for the patient and then gives the phone to them. Sometimes the unit secretary will give the patient the portable phone. She was able to show the surveyor the portable phone located in the nurse's station. She stated she will dial the phone number on the portable phone also. Any phone the patients use the staff will dial the numbers for them to monitor who they are calling.

On 1/26/11 at 12:00 p.m. there were five children observed eating their lunch in the children's unit. Interviews were conducted with the five patients. They all stated they have used the phone while staying in the unit. They have not used the portable phones. They have to use the phone at the nurse's station. All phone numbers were dialed for them.

Interview with the unit manager at 12:10 p.m. stated sometimes the patients have phone restrictions in their treatment plan. The patients are allowed to use the phone at certain times of day, they have no privacy and only a certain amount of time is allowed on the phone. When she was asked if any of these five patients have any phone restrictions she stated "no."

A review of the "Statewide Inpatient Psychiatric Program (SIPP)" program reading material showed on page eleven patients are allowed to make phone calls every other day. The patients are to make a list of people they want to call and these people are to be approved. These people are to be approved before the number is to be called.

The facility is violating these patients their right for private communications by requiring them to use phone at nursing station and having someone else dial a number for them. These patients have a right to make complaints to several agencies, including Agency For Health Care Administration and the abuse hot line and remain anonymous. The facility is not allowing them to remain anonymous. The facility monitors every call they make with full knowledge of the numbers they are calling.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to protect the rights of patients ensuring care in a safe setting, as evidenced by two specimen bottles with yellow liquid substance located in the public bathroom unsecured, unlabeled and with access to patients in the psychiatric unit; failure to secure a room that contained restraints attached to a bed in a seclusion room both in the children's, geriatric psychiatric, Highland Park psychiatric, and the emergency departments units, by Jackson South Community Hospital failure to ensure that equipment in the form of an oxygen cylinder was maintained to ensure a safe setting and by failure of the system to adhere to all Fire Life Safety requirements as noted in A-0709, A-0716, A-0724 and A-0726.

Findings include:

1. A tour of the psychiatric unit was conducted on 1/25/11 at approximately 9:15 a.m. Observation in the children's unit at 10:00 a.m. revealed two specimen bottles with a yellow liquid substance in them located in the public bathroom unsecured. Interview with the nurse manager at the time of the observation stated these two specimen bottles are urine samples of two patients that are admitted in this unit. Further review of these two bottles show there are no names on these specimen bottles. Any of the psychiatric patients in this unit had access to these two urine specimens.

2. Further observation of the children's unit revealed in one of the seclusion/quiet rooms a bed with restraints attached to it. This room's door was open and there was no patient in this room. Observations also showed there was no staff monitoring this room with the restraints. An interview with the nurse manager was conducted at this time. She stated the restraints are used for patients who require them for behaviors that could harm themselves or others. Any patient is allowed to use this room if they want to for quiet time if they want to get away from others. These restraints were not taken off the bed and the restraints were not secured from the patients in this unit. The availability of these restraints poses a risk to patients who might become accidently secured in them.

3. Observations in the geriatric unit at 10:30 a.m. showed there are two seclusion rooms. In one seclusion room there was a bed with restraints attached. The door to this seclusion room was open, exposing these restraints. There was no staff monitoring this room at this time. At the time of this observation an interview was conducted with the nurse manager. She stated the seclusion rooms are not locked when they are not being used. Any patient can go into these two room and use the beds with no supervision. She recognized the restraints on one of the beds and did not realize these restraints could cause harm to the psychiatric patients in this unit.

4. Observation in the emergency room unit at 11:00 a.m. showed a bed with restraints attached. There were no staff monitoring this room. An interview was conducted with the manager of the emergency room at this time. She stated several patients are in this emergency room due to psychiatric problems that have not been treated yet and some of them are in a crisis situation. These patients are waiting to be admitted , discharged or transferred. These restraints in this room were not secured and there was no monitoring of them.

5. Observation in the Highland Park unit at 11:30 a.m. showed a seclusion room with restraints attached to the bed. The door of this seclusion room was open. There were no staff monitoring this room. Psychiatric patients were observed moving freely in this unit. An interview was conducted with the unit manager at this time. She stated any patient is able to go into this seclusion room for quiet time. She was not aware the restraints attached to this bed could cause a threat to the safety of the patients and staff of this unit.

Therefore, with the observations throughout the units of these restraints being unsecured and exposed to the psychiatric patients, the environment was not maintained for the safety and well-being of the patients.

6. During a tour of the Jackson South Community hospital on [DATE] at approximately 2:31 p.m., an unsecured oxygen cylinder was observed standing upright in patient room #205.

This finding was confirmed in an interview with the Associate Nurse Manager at the same time.

Please refer to Fire Life Safety requirements as noted in A-0709, A-0716, A-0724 and
A-0726 for additional information.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review and interview the hospital failed to update and revise nursing procedures for current scope of practice for medication administration. The facility failed to ensure physician ordered medications were administered as ordered for 2 Patients (#75 and #45)

Findings include:

1. On 1/24/11, at 2:00 p.m., a review of policy and procedure for administration of medication was conducted with the Interim Director of Pharmacy. Policy, Code Number.400.024, date 3/20/08, title, Personnel Allowed to Administer Medication was reviewed, stated: Patient Care Associates (PCA) may administer medication as directed by physician. The PCA may not administer intravenous medications. Personnel trained in the procedure may apply topical medications, rectal suppositories for evaluation and enemas as directed by an RN/LPN. Additionally, the policy stated : In Children 14 years of age and younger, personnel trained in the procedure may administer oral medium chain triglycerides oil, vitamins and nystatin suspension that have been prepared by the RN/LPN. Interview of the Interim Director of Pharmacy concluded that she was not familiar with this policy, or how unlicensed staff would be given access to the medications, safely administer medications, or observe for affects of the medications.
On 1/25/11, an interview with the Chief Nursing Officer, regarding this medication administration policy was conducted. She was not familiar with the origin or the implementation of the policy. Further investigation found that currently, no patients are receiving medications administered by the Patient Care Associates. The hospital commenced to draft a revision to this policy during the survey.

2. On 1/25/11 review of Patient #75's medical recorded reveal they were admitted on [DATE] with a primary diagnosis of cardiac arrest. A physician order for Heparin Sodium 5000 unit (an anticoagulant) every 8 hours was ordered on [DATE]. A physician telephone order dated 1/21/11 at 2104 (9:04 p.m.) item #5 states "stop all anticoagulant and anti-platelets". Further review of the medication administration record revealed Patient #75 was administered Heparin Sodium 5000 units at 22:00 (10:00 p.m.) after receipt of the stop order.
On 1/25/10 at 11:00 a.m. an interview with the Director of the Intensive Care Unit (ICU) was conducted. She had reviewed Patient #75's medical records and confirmed the physician had ordered a stop to all anticoagulant and anti-platelets on 1/21/11 at 9:04 p.m. via a physician telephone. She also stated the nurse who had received this order proceeded to administered the Heparin Sodium 5000 units at 10:00 p.m..
On 1/25/11 at 1:00 p.m. an interview with the physician revealed he had called the nursing station and had given the order to stop the Heparin 5000 unit because he wanted to perform a surgical procedure the next day. He further stated while he did not perform the procedure as planed the 10:00 p.m. Heparin Sodium on 1/21/11 should not have been given by the nurse as per his telephone orders.

3. On 1/27/11 review of Patient #49's medical records revealed a physician order for Benadryl 50mg capsule to be administered at bedtime. The medication administration record (MAR) revealed Patient #49 received the medication on 1/03/11 at 21:00 (9:00 p.m.) and again at 22:48 (10:48 p.m.). Further review of the medical record did not reveal an order for the second dose of Benadryl 50mg to be administered at 10:48 p.m.

On 1/27/10 at around 10:00 a.m. an interview with the Director of Patient Care Services (DPCS) was conducted. She had reviewed Patient #49's medical records and confirmed Patient #49 was ordered a onetime dose of Benadryl 50mg to be administered at bedtime. She also confirmed there was no physician order or clarification for the second dose of Benadryl 50mg to be administration at 10:48 p.m.
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
Based upon record review and interview it was determined the facility and medical staff failed to enforce Medical Staff By-laws, Rules and Regulations to ensure completion of Medical Records within 30 days following discharge.

Findings include:

A review of the Medical Staff By-laws on 1/26/11 at 10:00 a.m. revealed in Section A-10(4) a requirement for medical records to be completed within 30 days of discharge. The Rules and Regulations in Article 8, item 1 on page 35 state the physician's admitting privileges will automatically be suspended for delinquent medical records older than 30 days "except for good cause shown".

A review of the hospitals delinquent record rate work sheet for a rolling 12 month timeframe from January 2010 through December 2010 revealed a delinquency rate from a low of 19.1% in September 2010 to a high of 33.3% in March 2010. The 12 month average for 2010 was 28.4%.

In an interview on 1/26/2011 at 11:00 am with the Vice President for Revenue Cycle, Receivables Manager, and Interim Health Information Manager (HIM) the surveyor asked why the delinquency rate was so high. The surveyor was informed the facility was significantly below the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) threshold of 50% for delinquent medical records greater than 30 days.

The surveyor reviewed Federal Standard A-469 for completion of medical records which requires all medical records to contain a final diagnosis within 30 days of discharge and all medical records to be complete within 30 days of discharge or outpatient care.

The facility representatives present stated they were not familiar with the Federal Standard for completion of Medical Records. The Receivable Manager stated he believed that if they were in compliance with JCAHO standards they were in compliance with Federal Standards.

The surveyor acknowledged this was correct so long as the facility maintained its deemed status. The surveyor noted the facility had lost its deemed status and was now being reviewed for compliance with Federal Standards and Federal Conditions of Participation. The surveyor noted the Federal requirements for completion of Medical Records was more stringent than JCAHO standards.

The Vice President for Revenue Cycle, Receivables Manager, and HIM acknowledged they were not in compliance with Federal Standards for completion of Medical Records.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, interview, and pharmacy policy review, the hospital did not dispose of remaining medication in single-use vials. Open, Single-use vials of medications remained accessible in the Neonatal Intensive Care Unit Pharmacy for dispensing.

Findings Include:

Observations of the pharmacies were conducted on 1/24/11, with the Interim Director of Pharmacy. Observed in the NICU (Neonatal Intensive Care Unit) Pharmacy on an open shelf was Furosemide 10 mg per ml, 2 ml vial. A label was attached to the single use vial, stating "open 1/24". The surveyor asked if the vial had been opened and a dose removed. The pharmacist stated that the vial was opened and a portion removed. The surveyor asked how long he would keep and use the medication in the single dose vial. He responded that it was OK to use up to 24 hours after opening. I reviewed the labeling with him that it stated "single use". The Interim Director stated that she would obtain the policy and current literature on single dose vial use.

Observation of the Pediatric Pharmacy was conducted after the NICU Pharmacy, along with the Interim Director of Pharmacy, at 2:10 p.m. The surveyor asked the pharmacist if single dose Furosemide could be used more than one time. The pharmacist stated "yes, it is good for up to 24 hours after open". No open single use vials were observed in the Pediatric Pharmacy.

Review of the hospital policy, Code No. 400.079, dated 1/28/08, title, Expiration Dates of Single and Multiple Use Medication Containers, was conducted with the Interim Director of Pharmacy on 1/25/11, at 9:20 a.m. She stated the policy nor the literature uphold the reuse of single use vial for the 24 hour period staff stated was acceptable. The policy stated: Pharmacy only- Only single-dose parenteral additives/medications that have been opened/punctured under aseptic conditions and kept continuously under a laminar/vertical flow hood may be reused and discarded 6 hours after initial needle puncture, unless otherwise specified by the manufacturer, whichever is less.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on record reviews, interviews and observations, the hospital failed to maintain it's facilities to conform to all Life Safety Fire regulations.


The findings include:


1. The facilities, and interviews with the staff, it was determined that the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction in accordance with NFPA 101-2000, 19.3.3.1, 19.3.3.2
Please refer to K-0015 for additional information.


2. The facility, it was determined that the facility failed to ensure that the corridor doors were constructed properly, able to resist the passage of smoke, and have suitable means for keeping the door closed without impediments to closing, in accordance with NFPA 101-19.2.2.2
Please refer to K-0018 for additional information.

3. The facility, and interviews with the staff, the facility failed to maintain the stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings in accordance with NFPA 101-2000 and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life.
Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
Please refer to K-0020 for additional information.

4. During tour of Jackson Health System, it was determined that the facility failed to properly maintain the required Fire/Smoke barrier penetration(s), which have not been fire stopped or smoke sealed per the requirements of NFPA 101. This condition could allow fire/smoke to travel from one smoke compartment to other smoke compartment, thus endangering occupants of facility.
Please refer to K-0023 for additional information.

5. The facility failed to maintain hazardous area separation. This condition may allow smoke and/or smoke from a fire to enter adjacent areas, and endanger occupants.
Please refer to K-0029 for additional information.

6. The facility, it was determined that the facility failed to ensure that an adequate number of exits are provided for each fire section of the building.
Please refer to K-0032 for additional information.

7. During tour of Jackson Health System, it was determined that the facility failed to provide exit access from the building without the use of a special tool or knowledge from the egress side. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.
Please refer to K-0038 for additional information.

8. The facilities, it was determined that the facility failed to ensure the fire alarm system was tested and installed in accordance with NFPA 72 (the standard for the installation of fire alarm systems), and maintained in reliable operating condition. This could delay or deny the required early warning of fire in the building.
Please refer to K-0052 for additional information.

9. The facility records and interview with the staff, it was determined that the facility failed to test the smoke detectors as frequently as required, and maintain the detectors in reliable operating condition. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.
Please refer to K-0054 for additional information.

10. The facility failed to maintain supervision of sprinkler system control valves. This condition may cause a valve to be inadvertently turned off, impacting the suppression systems capability in the event of a fire.
Please refer to K-0061 for additional information.

11. The facility failed to ensure that the automatic fire sprinkler system was tested as required, installed and maintained as required, in accordance with NFPA 13 & 25. This renders the equipment unreliable, and in the event of a malfunction during a fire could delay or deny extinguishment.
Please refer to K-0062 for additional information.

12. The facility records, it was determined that the facility failed to inspect the fire extinguishers as frequently as required, and maintain the extinguishers in reliable operating condition, in accordance with NFPA 101 and NFPA 10.
Please refer to K-0064 for additional information.

13. The facility, and interviews with the staff, it was determined that the facility failed to provide ashtrays of safe design in the designated outdoor facility smoking area in accordance with NFPA 101 19.7.4.
Please refer to K-0066 for additional information.

14. During tour of Jackson Health System, a review of the facility records and interviews with the staff it was determined that the facility could not confirm the flammability ratings of the decorations in use in the facility in accordance with NFPA 101-2000 19.7.5.2, 19.7.5.3, 19.7.5.4. The facility personnel had no available verification that the decorations had been treated or were effectively flame retardant or flame resistant. With no available documentation, flame retardant labels, or purchasing records for the decorative plastic plants and moss-like substances, the flame retardant ratings could not be substantiated or confirmed.
Please refer to K-0073 for additional information.
VIOLATION: ALCOHOL-BASED HAND RUB DISPENSERS Tag No: A0716
Based on observations made during tour of the facility, and interviews with the staff, it was determined that the facility failed to correctly install mounted alcohol dispensers in accordance with NFPA 101- 19.3.2.7 and CFR 403.744.


The findings include:

Please refer to K-0211 for additional information
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and record review the facility failed to ensure that infection control measures were enforced as it pertained to their policy and procedures, to ensure patient ' s were free from harmful microorganisms as evidenced by; Facility failure to ensure that food was stored and prepared under sanitary conditions. Facility failure to maintain food service equipment in safe operating condition resulting in failure to store food under safe, sanitary conditions and failure to properly sanitize dishes and equipment. Facility failure to monitor temperature at all critical control points and failure to hold cold food at safe temperatures. Observation and interview, the Jackson South Community Hospital facility failed to ensure that equipment in the form of an oxygen cylinder was maintained to ensure a safe setting.

The findings Include:
Jackson North Kitchen
Observation of the facility's North Campus kitchen on 1/24/2011 at 11:04 a.m. revealed the following:

A tour of the dish machine area revealed there was a large pipe located near the floor of the dish machine. The pipe was designated for hot water to be utilized for the dish machine. The pipe was insulated with a sliver foil, that was observed to be extremely worn, and exposed the interior insulated lining, which was hanging from the pipe, and confirmed to be fiberglass by the Food Service Director (FSD).

Ongoing Observation of the dish machine revealed the soiled dishes going through the wash cycle of the dish machine. The temperature gauge designated for the wash cycle was observed not moving. When the FSD was question on how his staff assures the wash cycle is at the proper/accurate temperature, the FSD replied; we have been using a paper temperature test strip, as a temporary measure. When the FSD was questioned on how long the wash cycle temperature gauge has not been working, he replied since our company took over the food contract in December 2010.

Observation of the walk in freezer revealed the interior frame of the door was observed to have a large accumulation of ice. Further observation revealed that there was an accumulation of frost on the boxes in the freezer, as well as a layer of ice on the floor. Observation of the interior temperature of the freezer was a minus 4 degrees, and the food was observed to be frozen/firm to the touch. When the Food Service Director (FSD) was questioned on the condition of the freezer, the FSD validated there were problems with the freezer door. After Survey intervention the FSD was requested to test the sealing quality of the exterior freezer door by placing a dollar bill in the door to ensure the seal of the door was secure. Results of the test did reveal that the seal to the door seemed to appear tight. The FSD also said that there have been problems with the freezer since company took over the food service contract December 2010.

Observation of the free standing ice machine revealed the exterior vents had an accumulation of dust, and the exterior of the ice machine as well had a large accumulation of lime build-up.

During observation of the tray line on 1/24/2011 at 11:15 a.m. revealed a pipe that was mounted from the ceiling close to the tray line, which was observed to have an accumulation of dust and dirt. Further observation of the tray line revealed the dinner rolls that being place on the patient ' s trays did not have a protective cover on them. At 11:35 a.m. the patient's trays were delivered to the fourth floor. The hostess proceeded to open the cart door which held the patient ' s food trays. She then proceeded to remove the patient tray from the cart in the hallway, exposing the unwrapped roll to the environment. Further observation revealed the hostess transporting the food cart down the hall with the cart door open continuing to expose the patient trays as well as the uncovered rolls on the trays to the environment.


Jackson South Facility

2. Observation of the facility's South Campus kitchen on 1/25/2011 at 9:30 a.m. revealed the following:

Observation revealed the cooks were preparing sandwiches. The cutting boards that were being used to place the sandwiches on for preparation were observed to be cut and gauged.

Further observation of the walk in freezer revealed a very thick accumulation of ice located on the exterior right side of the freezer close to the floor and adjacent to the opening of the freezer door. The interior of the freezer revealed a layer of frost on the boxes stored on the shelves as well as a coating of thin ice on the floor. The frame of the freezer door also revealed a coating of ice on the door frame. The Food Service Director (FSD) was questioned on the condition of the freezer, and replied the freezer door was not shutting properly, when our company took over the food contract, December 2010. Noted on the observation of the walk in freezer was the interior temperature was recorded at 0 degrees, and the food was firm to touch. Further observation of the walk in cooler adjacent to the freezer revealed large gaps between the ceiling and the side wall structure, as well as the metal walls observed to be rusty. This was also observed in the Produce cooler, Meat cooler and dairy cooler.

Further observation in the meat cooler revealed meat thawing on the bottom shelf. The meat was observed to be on a commercial size sheet pan, and the pan was observed to be filled to the rim with a red liquid.

Observation of the dish machine area revealed that the walls had a coating of a black substance on them. There was a drying rack in the room with two large plastic type material cutting boards on them. The cutting boards were observed to have deep gauges in them, as well as have a significant amount of black staining on the both boards. Further observation of the dish machine revealed that the thermometer for the wash cycle was not working. When the FSD was questioned on whether the thermometer was working she said they were using the test strips (test temperature). The FSD proceeded to demonstrate the use a test strip. When the test strip was transported through the dish machine it revealed that the rinse temperature was ok. When asked how they only take the temperature of the wash cycle exclusively, they were not able to demonstrate that. The FSD was asked to show the temperature log. Review of the temperature log for the dish machine demonstrated that 5 days out of 25 days the temperature was never recorded.

Observation of the back of the cooking range revealed there were loose and missing wall tiles.

Observation of the hospitals cafeteria revealed a reach in beverage cooler with metal shelves that were rusty.

Observation of all the ceiling air vents revealed they were coated with an accumulation of dust, grease, and dirt. The air vents were located above food preparation and serving areas.

Observation of the tray line service on 1/25/2010 at 11:12 a.m. revealed the following:

The Food Service Worker (FSW) who was plating up the hot food was observed to be wearing a hair restraint, which did not fully cover her head, and had long bangs hanging down over her forehead. The same FSW was observed to be wearing a jean jacket, which was continually observed brushing against the surfaces of she was dishing up the food. Further observation revealed a mail FSW assembling trays. This FSW was observed to have facial hear without any hair restraints. Further observation revealed a female FSW with extremely long eyelashes. When the FSD was questioned on the eyelashes, the FSD replied that they are false.

Observation of the patient tray delivery revealed the FSW with a badge hanging from her neck. As the FSW bent over to deliver the patient tray the badge was observed dragging over the tray.

3. Observation of the cafeteria in the Main Campus on 1/27/2011 at 9:00 a.m. revealed the following:

The dish room area revealed a vent located near the dish machine that was coated with a large amount of black dust, dirt and grime. The walls in the dish room revealed bare sheetrock, meaning the walls were porous, and had no paint or primer on them. Further observation revealed the corners/edges of the wall did not have a solid seal, but were taped together, and there were numerous holes in the wall as well.

The preparation area of the cafeteria revealed the metal frame surrounding the ceiling tile was observed to be very rusty, and the paint that was left on the frame was chipping and peeling off. As this observation was being made cooks were preparing raw chicken that was directly beneath the chipping and peeling paint.

4. Observation of the mental Health Hospital Clinic on the Main Campus at 8:30 a.m. on 1/28/2010 revealed the following:

The pot washing room revealed that clean pots and pans were being stored next to soiled pots and pans. The ceiling vent was coated with a thick layer of dust and dirt. The based board was separating from the wall, and the sheet rock behind the base board was crumbling. Further observation of the hand washing sink revealed it was not accessible to be utilized for hand washing, being the rack of soiled pots and pans were blocking the sink. Observation also revealed the pipes underneath the hand washing sink were not observed to have estuations surrounding the pipes leaving a large gap in the wall.

5. In the cafeteria serving area there was a hand washing sink. Observed in the sink was an ice cream scoop. A FSW was observed washing her hands in the sink, and never removed the scoop. The FSW proceeded to dry her hands, but had no place to dispose of the paper towel, being there was no was receptacle in the serving/hand washing area.

Review of dietary policy and procedure #E004 titled Uniform Dress Code revealed: Long facial hair must be covered with a surgical mask and/or hood.

Review of facility policy and procedure #G004 Section: Infection Control, titled " Dress Code and Personal Hygiene Nutrition Services " revealed " Jackets if worn must be white and of the type as prescribed by the uniform presented to management. White vests may be worn. In cold weather while working you are permitted to wear a plain yellow or white long sleeve jersey under your uniform shirt. Plain white button down sweater is also acceptable. No other color, sweater or jacket is permitted. "

6. Observation of the Main Campus kitchen on 1/24/11 beginning at 10:00 a.m. during the initial tour revealed the following sanitation concerns regarding food handling, food storage, preparation, and service.

-Dietary staff observed sweeping the floor next to the steam table where uncovered food was being plated.

- Dietary staff member observed leaving the tray line to remove food from a reach in refrigeration unit. The staff was observed touching the handle of the refrigeration unit and several sheet pans inside the unit with gloved hands. The staff then returned to the steam table area and continued to plate food without changing the gloves and/or washing her hands. The staff was next observed handling food with the same gloves, picking up cheese to prepare a sandwich. The staff pressed the cheese onto the sandwich with the palm of her hand using the full length of the glove.

-Dietary staff members observed frequently leaving the tray line area to remove food items from various refrigeration units, each time touching the handles of the units and storage pans inside the units with gloved hands. This staff member was observed placing uncovered dessert and salad items on serving tray with the same gloves. She was observed placing her thumb inside the food contact surface of each bowl. Observation revealed no gloves changed and/or hand washing during this service.

-Tray line supervisor was observed using a soiled napkin to clean her gloves. The supervisor continues to work in the tray line area wearing the same gloves.

-Dietary staff member observed picking up two hamburger patties with gloved hands and handing then down the line to another employee who was observed preparing sandwiches with gloved hands. Both employee had been observed leaving the tray line to remove food items from the reach in refrigerators, touching the handles and storage trays with gloved hands. Neither employee was observed changing gloves and/or wash hands prior to touching food items with soiled gloves.

-Observation on 1/24/11 at 10:55 a.m. revealed two large cutting boards in the bakery area of the kitchen. The integrity of the cutting boards was heavily damaged. Both boards had deep cuts which contained a black residue. Interview on 1/24/11 at 11:00 a.m. with the Executive Chef (EC) revealed that these cutting boards were removed for cleaning weekly and the surfaces were cleaned after each use. The EC attempted to turn the boards over, but reported that reverse sides were equally as damaged. The chef reported that the boards needed to be replaced as the work surface could no longer be adequately cleaned due to the deep cuts in the surface of the boards.

Review of facility policy and procedure #F008 Section: Sanitation and Infection Control titled Cutting Boards revealed replace all cutting boards with grooves and pits 1/8 inch or deeper that cannot be cleaned and sanitized using routine cleaning and sanitizing procedures.

-Observation on 1/24/11 at 11:00 a.m. in the bakery area revealed a soiled bin containing what appeared to be flour. The bin contained no label to identify the food product. The bin contained a large scoop with the handle in direct contact with the food item. The EC removed the scoop and confirmed that scoops should not be stored inside the bins.

Observation on 1/26/11 at 10:05 a.m. in the cafeteria kitchen revealed a staff member utilizing the three compartment sink to clean and sanitize dishes and utensil. When requested to check the sanitizer level, the staff removed a test strip from a quaternary test kit. The staff held the test strip in the water for approximately five seconds, stating that she holds the strip until it changes color. The staff member then needed to be instructed by the cafeteria manager to hold the strip up against the test kit. When asked what the sanitizer level should be, she stated that strip should be light green. Observation revealed the strip registered approximately 50 ppm (parts per million) when compared to the test kit. Manufacturer instructions revealed the recommended level between 150-400 ppm. Further observation revealed the sanitizer sink was filled approximately 6 inches above the marked fill line and the faucet continues to drip dispensing water into the sink further diluting the sanitizer.

Observation on 1/28/11 at 8:50 a.m. in the Mental Health Clinic kitchen revealed the following:
-A scoop holder containing a scoop was mounted on the wall next to the ice machine. The wall directly above the scoop holder had been plastered, but not sanded or painted. The plaster above the scoop holder was cracking with loose pieces of plaster chipping directly above the ice scoop.

-Internal thermometers were missing from the walk-in freezer, one reach in freezer and two reach in refrigerator units. The exterior built in thermometer on the walk-in freezer was broken (no temperature registered). The two door reach-in located in the cafeteria area had an external thermometer which registered 42 degrees F. The base of the unit contained a large amount of water pooling on the floor. This unit contained no internal thermometer. Interview on 1/28/11 with the GM revealed that this unit had been repaired on 1/27/11 and had just been put back in service. The temperature log reflected 52 degrees F. The GM confirmed that an internal thermometer should be placed inside the unit to monitor and confirm that the unit was functioning properly.

7. Observation on 1/24/11 at 10:35 a.m. revealed dietary staff operating a multi-tank conveyor type dish machine. The staff was observed processing patient serving trays and dome lids through the dish machine. Observation revealed the temperature gauges on the unit registering the wash temperature at 123 degrees Fahrenheit (F) and a final rinse temperature of 155 degrees F. Observation on 1/24/11 at 11:28 a.m. during return to the dish room area revealed the wash temperature registering 132 degrees F and the final rinse 145 degrees F. Observation on 1/24/11 at 11:30 a.m. revealed the wash temperature registering 126 degrees F and the final rinse 163 degrees F. Observation on 1/24/11 at 11:35 a.m. revealed the wash temperature registering 125 degrees F and the final rinse 149 degrees F. The Executive Chef (EC) used a temperature strip to confirm temperature. The strip was attached to a dome lid and sent through the dish machine cycle. The temperature strip did not register temperature ranges between 160-180 degrees F.

Review of temperature logs posted reflected standard wash temperature should be 150 degrees F and final rinse temperature 180 degrees F. Review of the January 2011 temperature log reflected the wash temperature recorded below acceptable standards seventeen times from 1/1/11 through 1/24/11 and final rinse temperature below acceptable standards twice from 1/1/11 through 1/24/11. Temperature recorded on the log for breakfast 1/24/11 included wash 125 and final rinse 153 degrees. These temperatures were recorded prior to observation of staff operating the dish machine on 1/24/11 at 11:25 a.m.

Interview on 1/24/11 at 11:30 a.m. with the General Manager (GM) revealed that the dish machine was operated as a high temperature unit using heat to sanitize, but a chlorine sanitizer was connected as a back up in the event the standard temperature were not reached. Observation of the machine revealed the use of detergent and a rinse agent only, no sanitizer was observed connected to the unit. Interview on 1/24/11 at 11:25 a.m. with the Assistant Manager (AM) revealed that the dish machine was a high temperature machine and a sanitizer was not being used to sanitize the dishes. The machine utilized heat only to sanitize. At this time the staff was instructed to shut the machine down for service and use the three compartment sink for washing and sanitizing dishes. The staff was instructed to re-wash the dome lids, but the serving trays were not removed from the drying racks. Maintenance was contacted to request service to the dish machine.

Observation on 1/24/11 at 1:00 p.m. revealed the dish machine remained out of service.
Observation at the three compartment sink revealed a staff member washing and rinsing dishes and equipment. The staff was observed washing and rinsing four steam table pans. The third sink compartment (sanitizing section) was approximately full. The staff member was observed removing the pans from the rinse compartment and placing them directly on a drying sink. The pans were never immersed in the third compartment to be sanitized. Interview on 1/24/11 at 1:00 p.m. revealed that the third sink was used to sanitize the dishes. No explanation was given for not setting up the third compartment. Observation revealed Oasis Quat-146 attached above the third sink compartment to be dispensed automatically when the sink was filled.

Observation on 1/25/11 at 2:00 p.m. revealed an automatic pot washing machine in operation.
Observation of the machine gauges revealed the wash temperature registering 150 degrees F, rinse 160 degrees F, and the final rinse reached 185 degrees. Review of the temperature log posted for January 2011 reflected that staff was not recording the final rinse temperature. Interview on 1/25/11 at 2:00 p.m. with the Administrator revealed all three temperatures should be monitored and recorded on the log.

Review of a service report dated 1/25/11 revealed the dish machine had been temporarily repaired to ensure that the washer booster reached 180-190 degrees. Repair to be finalized 1/26/11. Observation on 1/25/11 at 2:40pm following service revealed the wash temperature registering 113 degrees F and the final rinse 201 degrees. Interview on 1/25/11 at 3:00 pm with the GM and the Patient Services Operations Manager revealed the all automatic dish washing machines including units in the main kitchen, cafeteria and the pot washing machine would be equipped with a sanitizing solution for conversion to chemical sanitizing in the event that the machine malfunctioned and safe temperatures were not reached.

Observation on 1/24/11 at 11:05 a.m. revealed walk-in freezer unit #20A with the door ajar. A staff member was observed attempting to close the freezer door using a cord attached to the handle of the unit. Once the cord was attached to the handle and the clasp closure, the gap between the door and the frame was approximately three inches wide. Observation revealed a heavy build up of ice surrounding the door casing and on the threshold at the base of the door. The door casing was missing and exposed splintered wood was observed on the right side of the casing. The interior and exterior panels were separating from the door at the top and bottom of the door exposing the insulation. The exterior dial thermometer registered 38 degrees F and the exterior digital thermometer registered 24 degrees F. Observation inside the unit revealed a heavy build up of ice and frost on the floor and walls of the unit. All of the food stored inside the unit had a film of ice/frost covering the boxes. The ceiling of the unit was covered with water droplets which were observed dripping onto the food stored in the unit. Multiple boxes were not properly sealed allowing frost to accumulate directly on the food items. This included, but was not limited items such as green beans, raw breaded cod patties, and whole baby carrots. Multiple items showed frost build up inside the sealed plastic packaging and evidence of freezer burn. Water was observed splashing from the condenser fans and there was ice accumulated on the insulated pipes extending from the unit. The interior thermometer registered 38 degrees F. Interview on 1/24/11 at 11:15 with the GM revealed that the unit was currently in the defrost cycle and although the door did not fully closed, the temperature of the unit was high due to the defrost cycle. All food items were frozen solid to touch during the observation.
Observation revealed two pallets of bagged iced stored inside the unit. The bags were covered with a heavy accumulation of ice/frost. Interview on 1/24/11 at 11:20 am with the EC revealed that this ice was used for patients on the South Wing of the hospital because this unit did not have an ice machine. The EC confirmed that this ice was used for patient consumption. Interview with the EC and the GM at 11:20 revealed that the freezer door had been in this condition since on or before 12/1/10 when the company they worked for assumed that food service management contract. A work order was provided dated 1/7/11 stated that the walk in cooler needs a new door.

Review of facility policy and procedure #B007 titled " Storage Times and Temperature revealed " Temperatures of food storage areas and cold food vendors are monitored and action taken to maintain temperatures within ranges recommended by licensing and surveying agencies. Frozen storage minimum -10 degrees F, maximum 0 degrees F. Review of policy and procedure #F016 titled " Ice Handling " revealed Ice must be protected from splash, drip, during storage and service.

Interview on 1/26/11 at 8:45 a.m. with the hospital ' s Vice President of Quality revealed that the freezer was being taken out of service pending repair and/or replacement of the door. He reported the staff was instructed to remove all food for storage in an alternate freezer unit. A copy of purchase order dated 1/3/11 was provided which included the proposal for replacement of the freezer door and floor ramp. The VP of Quality stated the food should have been removed from the unit and transferred to an alternate freezer prior to this date pending repair.

Interview on 1/26/11 at 9:00 a.m. with the Nutrition Service Administrator confirmed that freezer 20A is in the process of being taken out of service. All of the food will be moved to freezer #20B. The administrator had no explanation why the food had not been moved prior to this date and confirmed concerns with the unit since on or before 12/1/10 when the new food service contracted was initiated.

8. Observation on 1/26/11 at 10:30 a.m. revealed a meal cart containing 24 patient trays removed from a walk-in refrigerator in the main kitchen. The refrigerator temperature registered 38 degrees F at the time the cart was removed. The cart was transported to the South Wing 5 unit pantry. All trays were transferred from the cart to the holding unit. Interview 1/26/11 at 10:35 with the Assistant Manager revealed that the unit would be set for the cool down mode to maintain food temperatures at or below 40 degrees until approximately 11:20 a.m. and then set to re-thermalize for service at 12 noon. Upon return to the pantry area, the unit began beeping which according to the manager signaled completion of the cycle.
Observation of the re-therm unit revealed external temperatures registering 228 degrees F on the hot side and 50 degrees F on the cold side. Facility staff requested that further observation be completed on the West Wing 7 unit where the cart contained an extra tray for testing the food temperatures as requested by the surveyor. The post re-thermalization temperatures on the exterior of this unit registered 221 degrees on the hot side and 50 degrees on the cold side. At 12:50pm, a test tray was removed from the unit. A digital thermometer was used to test food temperatures with results as follows: soup 181, roast beef 174, potato wedges 172, corn 176, juice 45, milk 51.2, and applesauce 56.6. Interview on 1/26/11 at 12:100pm with a Nutrition Services Aide revealed that food temperatures are not monitored and recorded at the end of the cool down cycle or at the end of the re-therm process prior to service to patients. The employee reported that prior to 12/1/10 when the new food service company was hired; they used to check food temperature of one tray daily alternating carts and alternating meals. A log was maintained and if the temperatures were not correct, they were reported to the manager. The employee confirmed that this temperature testing had not been continued after 12/1/10 when the new company took over. The GM and the Nutrition Services Administrator confirmed that the cold food temperature exceeded 40 degrees F and were not acceptable holding temperatures. The GM reported that test tray temperatures were monitored three times per week at the end of delivery, but confirmed that food temperatures were not monitored at the end of the cool down cycle or the re-therm process prior to distribution to patients. Review of the post delivery test tray results revealed frequent concerns with cold food temperatures not being acceptable according to post delivery standards set by the facility. Review of facility policy and procedure titled " Test Trays " revealed 6. If food temperatures are inappropriate, a corrective action plan for better holding procedures should be implemented and 7. A follow up test tray will be done the next day to evaluate effectiveness of the corrective action plan.
Reviews of test tray results reflect no follow up test tray results the day follow documented inappropriate temperatures results. The GM and the Administrator confirmed that since temperatures were not monitored at point of service, there was no means of determining at which point in time the cold food temperatures had risen above the acceptable holding temperature of 40 degrees F. When asked about general maintenance and calibration of the holding/re-thermalization units, the Administrator reported that the unit had a built in alarm system to signal if appropriate temperatures are not reached, but otherwise no random or routine testing is done to assure hot/cold food temperatures are maintained in a safe temperature range.

Review of the facility policy and procedure #B0167 titled: Food Handling Guidelines revealed Cold Holding: Foods should be held cold for service at a temperature of 41 degrees F or less.

9. A. The Main Kitchen at the Main Campus (0109) Diagnostic Treatment Center Basement houses a fire suppression system for the commercial cooking equipment. Inspection of the system revealed that the equipment under the hood was not aligned with the nozzles in the suppression system.


B. The Main Kitchen at the Main Campus (0109) Diagnostic Treatment Center Basement fire suppression system had nozzles that were in excess of 42 inches above the flame charbroiler making them in effective. The company that inspects and certifies the system verified and confirmed that this is an unacceptable installation.


C. While on tour of the Main Campus (0109) on 1/27/11, in the Mental Health Center, at 1:45 p.m., the Kitchen exhaust hood does not have liquid tight joints to contain grease laden vapors which develop from cooking processes.


D. While on tour of the Main Campus (0109) on 1/27/11, in the Mental Health Center, at 1:45 p.m., observation of the appliances located below the hood perimeter are not at least 6 inches horizontally or more inside the hood outline.


E. While on tour of the Main Campus (0109) on 1/27/11, in the Mental Health Center, at 1:45 p.m., a manual over ride emergency fuel cut-off switch is located on the wall immediately above the deep fat fryer, which is not an approved location.


F. While on tour of the Main Campus (0109) on 1/27/11, in the Mental Health Center, at 1:45 p.m., the suppression system is listed on the contracting vendor inspection reports, as meeting all requirements of an Underwriters Laboratories 300 wet chemical installation. It does not. The reports from calendar year 2009 indicate that all of the cooking appliances are electric. They are not, as the range is natural gas fueled. Staff did not have knowledge of where the gas solenoid valve was located, which generally is as close as possible to the equipment. Through an investigative procedure, the solenoid was found to be above the hard surface ceiling adjacent to the cooking area. The facility, when requested, could not provide any inspection reports from calendar year 2010. The system has a (one only) spare Grinnell type EA-1 Protecto-spray nozzle, in the event of a need for replacement of any nozzle currently in service. Without a spare nozzle the cooking equipment is prohibited from being used.


G. On 1/28/11, at the Main Campus (0109) Diagnostic Treatment Center, in the main cafeteria, at 1:35 pm, it was determined that the commercial kitchen equipment was not properly positioned under the hood system. It was observed that the deep fat fryer was not being fully protected by the suppression system. Staff indicated that this equipment was moved for cleaning and was not placed back in the original position which renders the suppression system ineffective. This condition was confirmed by the director of the kitchen.

H. On 1/24/11 at the South Campus (0309) at 3:15 pm grease laden hoods and filters were observed, and on 1/25/11 during kitchen tour from 1-2:30 pm, this condition remained.


I. On 1/26/11, at the Main Campus Mental Health Building, the dietary cooler with sprinkler heads were dated 1999 rendering them expired..


J. On 1/26/11, at the Main Campus (0109) Mental Health Building, a K -Series extinguisher with wand was observed in the kitchen. These wand on the extinguisher is no longer in compliance.


K. On 1/25/11, at the South Campus (0309), a K -Series extinguishers with wand was observed in the kitchen. The wand on the extinguishers are no longer in compliance.


10. During a tour of the Jackson South Community hospital on [DATE] at approximately 2:31p.m., an unsecured oxygen cylinder was observed standing upright in patient room #205.


This finding was confirmed in an interview with the Associate Nurse Manager at the same time.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observations, record reviews and interviews, the facility failed to assure proper ventilation, lighting and temperature controls for it's facilities.


The findings include:

1. During tour of the facility, it was determined that the facility failed to maintain illumination of the means of egress. Illumination of the means of egress is required to the extent that the failure of any single fixture will not leave the area in darkness. Lack of lighting in the stairwell could cause occupants of the building to experience delays in egress or result in possible fall and trip hazards.
Please refer to K-0045 for additional information.

2. The facility failed to ensure that the emergency lighting was tested as required, and maintained in reliable operating condition. This could delay or deny safe exiting from the facility in an emergency. Emergency lighting is also required to service the generator and switchgear in the event of a simultaneous failure of the electric utility that serves the facility and the generator.
Please refer to K-0046 for additional information


3. The facility failed to maintain exit signs in reliable operating condition. Exits shall be marked by an approved sign readily visible from any direction of exit access'. Failure to maintain these lighted directional signs could lead to confusion and possibly panic should an emergency evacuation (horizontal exiting) become necessary. Signage indicating the location and direction to exits is required to insure the safe egress of the building occupants in the event of an emergency.
Please refer to K-0047 for additional information


4. During tour of Jackson Health System, it was determined that the facility failed to ensure the Ventilation System was maintained in reliable operating condition. This would promote unbalanced air pressure in the facility, promote sustained odors in the facility, and raise potential infection control issues in the facility.
Please refer to K-0067 for additional information.

5. During tour of the facility, it was determined that the facility failed to provide documentation that all of the generators and ancillary equipment were tested and certified at an optimal state in accordance with NFPA 101 and NFPA 110 " Standard for Emergency and Standby Power Systems ". NFPA 110- 8.4.9: Level 1 EPSS shall be tested for the duration of its assigned class for at least 4 hours at least once within every 36 months. Reference: NFPA 110-Standard for Emergency and Standby Power Systems 8.3.8 "A fuel quality test shall be performed at least annually using tests approved by ASTM standards."
Please refer to K-0144 for additional information.
VIOLATION: GOVERNING BODY Tag No: A0043
This Condition of Participation is not met based on the governing body failing to show responsibility for the conduct of the hospital as an institution as shown by it's failure to honor Patient Rights for care in a safe setting and failure to maintain the physical plant and failure to abide by Fire Life Safety regulations.

These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

The findings include:

Please refer to the citations listed below for additional, specific information:

1. A-0117
Based upon record review and interview it was determined Jackson Memorial South Hospital was not providing Medicare patients with the Important Message from Medicare as required for 7 of 7 Medicare recipient medical records reviewed (#63, 64, 66, 67, 80, 82, and 87) on 1/25/11.
2. A-0143
Based on observation, staff and patient interviews and records reviewed, the facility failed to honor patient right to personal privacy for making phone calls.

3. A-0144
Based on record review and interview, the facility failed to protect the rights of patients ensuring care in a safe setting, as evidenced by two specimen bottles with yellow liquid substance located in the public bathroom unsecured, unlabeled and with access to patients in the psychiatric unit; failure to secure a room that contained restraints attached to a bed in a seclusion room both in the children's, geriatric psychiatric, Highland Park psychiatric, and the emergency departments units, by Jackson South Community Hospital failure to ensure that equipment in the form of an oxygen cylinder was maintained to ensure a safe setting.

4. K 0015
Based on observations made during tour of the facilities, and interviews with the staff, it was determined that the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction in accordance with NFPA 101-2000, 19.3.3.1, 19.3.3.2

5. K 0018
Based on observations made during tour of the facility, it was determined that the facility failed to ensure that the corridor doors were constructed properly, able to resist the passage of smoke, and have suitable means for keeping the door closed without impediments to closing, in accordance with NFPA 101-19.2.2.2

6. K 0020
Based on observations made during tour of the facility, and interviews with the staff, the facility failed to maintain the stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings in accordance with NFPA 101-2000 and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life.
Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

7. K 0023
Based on observation made during tour of Jackson Health System, it was determined that the facility failed to properly maintain the required Fire/Smoke barrier penetration(s), which have not been fire stopped or smoke sealed per the requirements of NFPA 101. This condition could allow fire/smoke to travel from one smoke compartment to other smoke compartment, thus endangering occupants of facility.

8. K 0029
Based upon observations, staff interview, and record review, the facility failed to maintain hazardous area separation. This condition may allow smoke and/or smoke from a fire to enter adjacent areas, and endanger occupants.

9. K 0032
Based on observations made during tour of the facility, it was determined that the facility failed to ensure that an adequate number of exits are provided for each fire section of the building.

10. K 0034
Based on observations made during tour of the facility, it was determined that the facility failed to maintained stairs and stair towers in accordance with NFPA 101 Chapter 19.2.2.1. & chapter 7.

11. K 0038
Based on observations during tour of Jackson Health System, it was determined that the facility failed to provide exit access from the building without the use of a special tool or knowledge from the egress side. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

12. K 0045
Based on observations made during tour of the facility, it was determined that the facility failed to maintain illumination of the means of egress. Illumination of the means of egress is required to the extent that the failure of any single fixture will not leave the area in darkness. Lack of lighting in the stairwell could cause occupants of the building to experience delays in egress or result in possible fall and trip hazards.

13. K 0046
Based on a review of the facility records, and interview with the staff, it was determined that the facility failed to ensure that the emergency lighting was tested as required, and maintained in reliable operating condition. This could delay or deny safe exiting from the facility in an emergency. Emergency lighting is also required to service the generator and switchgear in the event of a simultaneous failure of the electric utility that serves the facility and the generator.

14. K 0047

Based on observations made during tour of the facility, and interviews with the staff, the facility failed to maintain exit signs in reliable operating condition. Exits shall be marked by an approved sign readily visible from any direction of exit access'. Failure to maintain these lighted directional signs could lead to confusion and possibly panic should an emergency evacuation (horizontal exiting) become necessary. Signage indicating the location and direction to exits is required to insure the safe egress of the building occupants in the event of an emergency.

15. K 0050

Based on a review of the facility records, and interview with the staff, it was determined that the facility failed to ensure the staff was trained in emergency fire procedures a frequently as required, consisting of at least one fire drill per shift per quarter, and Laboratory staff members must participate at least annually. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

16. K 0052

Based on a review of the facility records, interviews with the staff, and observations made during tour of the facilities, it was determined that the facility failed to ensure the fire alarm system was tested and installed in accordance with NFPA 72 (the standard for the installation of fire alarm systems), and maintained in reliable operating condition. This could delay or deny the required early warning of fire in the building.

17. K 0054
Based on a review of the facility records and interview with the staff, it was determined that the facility failed to test the smoke detectors as frequently as required, and maintain the detectors in reliable operating condition. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

18. K 0061
Based upon observations and staff interview, the facility failed to maintain supervision of sprinkler system control valves. This condition may cause a valve to be inadvertently turned off, impacting the suppression systems capability in the event of a fire.

19. K 0062
Based on a review of the facility records, and interview with the staff , it was determined that the facility failed to ensure that the automatic fire sprinkler system was tested as required, installed and maintained as required, in accordance with NFPA 13 & 25. This renders the equipment unreliable, and in the event of a malfunction during a fire could delay or deny extinguishment.

20. K 0064

Based upon observations made during tour the facilities, and a review of the facility records, it was determined that the facility failed to inspect the fire extinguishers as frequently as required, and maintain the extinguishers in reliable operating condition, in accordance with NFPA 101 and NFPA 10.

21. K 0066

Based on observations made during tour of the facility, and interviews with the staff, it was determined that the facility failed to provide ashtrays of safe design in the designated outdoor facility smoking area in accordance with NFPA 101 19.7.4.

22. K 0067

Based on observations made during tour of Jackson Health System, it was determined that the facility failed to ensure the Ventilation System was maintained in reliable operating condition. This would promote unbalanced air pressure in the facility, promote sustained odors in the facility, and raise potential infection control issues in the facility.

23. K 0069

Based on observations made during tour of the facility, it was determined that the facility failed to maintain the commercial cooking equipment in reliable operating safe condition, and to test the equipment in accordance with NFPA 96. This renders the equipment unreliable and could delay or deny extinguishment of a fire.

24. K 0070

Based on observations made during tour of the facility failed to ensure that prohibited space heaters were in use, and to follow the facility policy regarding space heaters. Space heaters with elements which exceed 212 degrees Fahrenheit are prohibited in health care facilities.
25. K 0071

Based on observations made during tour of the facility, it was determined that the facility failed to ensure that the integrity of laundry and trash chutes are maintained in accordance with NFPA 82.

26. K 0072
Based on observations made during tour of the facility, it was determined that the facility failed to ensure that the exit access corridors were clear and unobstructed at all times, to full instant use in case of fire or other emergency. This in the event of fire or any reason to evacuate from a portion of the facility to another section or outside for an area of refuge may be delayed or denied as a result of exit corridor obstruction.

27. K 0073

Based on observations made during tour of Jackson Health System, a review of the facility records and interviews with the staff it was determined that the facility could not confirm the flammability ratings of the decorations in use in the facility in accordance with NFPA 101-2000 19.7.5.2, 19.7.5.3, 19.7.5.4. The facility personnel had no available verification that the decorations had been treated or were effectively flame retardant or flame resistant. With no available documentation, flame retardant labels, or purchasing records for the decorative plastic plants and moss-like substances, the flame retardant ratings could not be substantiated or confirmed.

28. K 0076
Based on observations made during tour of the facility, it was determined that the facility failed to ensure that non-medical flammable medical gas is handled and stored in accordance with NFPA 99. Unsecured oxygen cylinders have the potential if knocked over can rupture at the neck of the cylinder causing a super oxygen enriched atmosphere, increasing the flammability of all surrounding building contents, and the cylinder itself becoming projectile endangering all building occupants.

29. K 0077

Based on observations made during tour of the facility, it was determined that the facility failed to ensure that medical gas is handled and stored in accordance with NFPA 99.

30. K 0104

Based on an observations made during tour of the facility, interviews with the staff, and a review of the facility records, conducted during the survey of Jackson Health System, it was determined that the facility failed to maintain the fire/smoke dampers in reliable operating condition. This condition could place the lives of the occupants in smoke environment should a fire occur and the fire/smoke dampers failed to respond.

31. K 130

Based on an observation, a defunct Life Safety system and its components have not been removed from the facility. The area of concern is the former roof top fire protection equipment for a Heliport landing pad at the East Tower.

32. K 0135

Based on observations during tour of the facility, and interviews with facility staff, the facility failed to adequately protect the building occupants from flammable and combustible liquids. The facility further failed to maintain fire protection and occupancy features necessary to minimize danger to life in accordance with NFPA 101-19.3.2, 10.3.5., and the NFPA 30 (Flammable Liquid Code).

33. K 0144

Based upon a review of the facility records, interviews with the staff, and observations made during tour of the facility, it was determined that the facility failed to provide documentation that all of the generators and ancillary equipment were tested and certified at an optimal state in accordance with NFPA 101 and NFPA 110 " Standard for Emergency and Standby Power Systems ". NFPA 110- 8.4.9: Level 1 EPSS shall be tested for the duration of its assigned class for at least 4 hours at least once within every 36 months. Reference: NFPA 110-Standard for Emergency and Standby Power Systems 8.3.8 "A fuel quality test shall be performed at least annually using tests approved by ASTM standards."

34. K 0147
Based on a review of the facility records, and interview with the staff during the Fire Life Safety survey, it was determined that the facility failed to ensure that all electrical wiring and electrical equipment are properly installed, tested as frequently as required, and maintained in reliable operating condition, tested as frequently as required, and maintained in accordance with NFPA 101, and NFPA 70.

35. K 0211
Based on observations made during tour of the facility, and interviews with the staff, it was determined that the facility failed to correctly install mounted alcohol dispensers in accordance with NFPA 101- 19.3.2.7 and CFR 403.744.
VIOLATION: PATIENT RIGHTS Tag No: A0115
This Condition of Participation is not met based on record reviews, observations and interviews. The facility failed to provide for a safe environment for all patients as it relates to: Fire doors not closing; Smoke compartments not isolated; Railings in stairwells not secured; Push handles on emergency doors not opening properly (delay too long); Doors with double locks; Missing directional signs (exit signs); Exhaust fans not working; Kitchen hoods and equipment issues; Portable space heaters used improperly; Obstructed corridors; Unsecured O2 tanks; Piped in medical gases with "clicker call lights" nearby; No fuel analysis - Generators; Line monitoring-live wires; Electrical panels not labeled; Important Message from Medicare not given; Failing to provide for Patient Rights to personal privacy and care in a safe setting.

These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

The findings include:

1. Jackson Memorial South Hospital was not providing Medicare patients with the Important Message from Medicare as required for 7 of 7 Medicare recipient medical records reviewed (#63, 64, 66, 67, 80, 82, and 87) on 1/25/11.

Please refer to A-0117 for additional information.

2. The facility failed to honor patient right to personal privacy for making phone calls.

Please refer to A-0143 for additional information.

3. The facility failed to protect the rights of patients ensuring care in a safe setting, as evidenced by two specimen bottles with yellow liquid substance located in the public bathroom unsecured, unlabeled and with access to patients in the psychiatric unit; failure to secure a room that contained restraints attached to a bed in a seclusion room both in the children's, geriatric psychiatric, Highland Park psychiatric, and the emergency departments units, by Jackson South Community Hospital failure to ensure that equipment in the form of an oxygen cylinder was maintained to ensure a safe setting.

Please refer to A-0144 for additional information.

4. The facility failed to ensure the staff was trained in emergency fire procedures a frequently as required, consisting of at least one fire drill per shift per quarter, and Laboratory staff members must participate at least annually. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

Please refer to K-0050 for additional information.

5. Observations during tour of the facility, it was determined that the facility failed to ensure that the exit access corridors were clear and unobstructed at all times, to full instant use in case of fire or other emergency. This in the event of fire or any reason to evacuate from a portion of the facility to another section or outside for an area of refuge may be delayed or denied as a result of exit corridor obstruction.

Please refer to K-0072 for additional information

6. Observations during the survey of Jackson Health System, it was determined that the facility failed to maintain the fire/smoke dampers in reliable operating condition. This condition could place the lives of the occupants in smoke environment should a fire occur and the fire/smoke dampers failed to respond.

Please refer to K-0104 for additional information.

7. The facility failed to adequately protect the building occupants from flammable and combustible liquids. The facility further failed to maintain fire protection and occupancy features necessary to minimize danger to life in accordance with NFPA 101-19.3.2, 10.3.5., and the NFPA 30 (Flammable Liquid Code).

Please refer to K-0135 for additional information
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
This Condition of Participation is not met based on the facility not maintaining the physical plant to ensure the safety of the patient as stated in Standards for A-0701, A-0709, A-0716, A-0724 and A-0726. and additional Fire Life Safety deficiencies (K-Tags)

These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

The findings include:

A-0701
The facility failed to assure the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured.

A-0709
The hospital failed to maintain it's facilities to conform to all Life Safety Fire regulations.

A-0716
The facility failed to correctly install mounted alcohol dispensers in accordance with NFPA 101- 19.3.2.7 and CFR 403.744.

A-0724
The facility failed to ensure that infection control measures were enforced as it pertained to their policy and procedures, to ensure patient's were free from harmful microorganisms as evidenced by; Facility failure to ensure that food was stored and prepared under sanitary conditions. Facility failure to maintain food service equipment in safe operating condition resulting in failure to store food under safe, sanitary conditions and failure to properly sanitize dishes and equipment. Facility failure to monitor temperature at all critical control points and failure to hold cold food at safe temperatures. Observation and interview, the Jackson South Community Hospital facility failed to ensure that equipment in the form of an oxygen cylinder was maintained to ensure a safe setting.

A-0726
The facility failed to assure proper ventilation, lighting and temperature controls for it's facilities.

Please refer to the specific Fire Life Safety deficiencies (K-Tags) listed below for additional information:

1. Observations during tour of the facilities, and interviews with the staff, it was determined that the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke compartments and smoke construction in accordance with NFPA 101-2000, 19.3.3.1, 19.3.3.2

Please refer to K-0015 for additional information

2. The facility failed to ensure that the corridor doors were constructed properly, able to resist the passage of smoke, and have suitable means for keeping the door closed without impediments to closing, in accordance with NFPA 101-19.2.2.2
Please refer to K-0018 for additional information
3. The facility failed to maintain the stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings in accordance with NFPA 101-2000 and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

Please refer to K-0020 for additional information

4. During tour of Jackson Health System, it was determined that the facility failed to properly maintain the required Fire/Smoke barrier penetration(s), which have not been fire stopped or smoke sealed per the requirements of NFPA 101. This condition could allow fire/smoke to travel from one smoke compartment to other smoke compartment, thus endangering occupants of facility.
Please refer to K-0023 for additional information

5. The facility failed to maintain hazardous area separation. This condition may allow smoke and/or smoke from a fire to enter adjacent areas, and endanger occupants.
Please refer to K-0029 for additional information

6. During tour of the facility, it was determined that the facility failed to ensure that an adequate number of exits are provided for each fire section of the building.
Please refer to K-0032 for additional information

7. During tour of the facility, it was determined that the facility failed to maintained stairs and stair towers in accordance with NFPA 101 Chapter 19.2.2.1. & chapter 7.
Please refer to K-0034 for additional information

8. During tour of Jackson Health System, it was determined that the facility failed to provide exit access from the building without the use of a special tool or knowledge from the egress side. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.
Please refer to K-0038 for additional information

9. During tour of the facility, it was determined that the facility failed to maintain illumination of the means of egress. Illumination of the means of egress is required to the extent that the failure of any single fixture will not leave the area in darkness. Lack of lighting in the stairwell could cause occupants of the building to experience delays in egress or result in possible fall and trip hazards.
Please refer to K-0045 for additional information

10. The facility failed to ensure that the emergency lighting was tested as required, and maintained in reliable operating condition. This could delay or deny safe exiting from the facility in an emergency. Emergency lighting is also required to service the generator and switchgear in the event of a simultaneous failure of the electric utility that serves the facility and the generator.

Please refer to K-0046 for additional information

11. The facility failed to maintain exit signs in reliable operating condition. Exits shall be marked by an approved sign readily visible from any direction of exit access'. Failure to maintain these lighted directional signs could lead to confusion and possibly panic should an emergency evacuation (horizontal exiting) become necessary. Signage indicating the location and direction to exits is required to insure the safe egress of the building occupants in the event of an emergency.

Please refer to K-0047 for additional information

12. The facility failed to ensure the staff was trained in emergency fire procedures a frequently as required, consisting of at least one fire drill per shift per quarter, and Laboratory staff members must participate at least annually. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

Please refer to K-0050 for additional information

13. During tour of the facilities, it was determined that the facility failed to ensure the fire alarm system was tested and installed in accordance with NFPA 72 (the standard for the installation of fire alarm systems), and maintained in reliable operating condition. This could delay or deny the required early warning of fire in the building.

Please refer to K-0052 for additional information

14. The facility failed to test the smoke detectors as frequently as required, and maintain the detectors in reliable operating condition. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

Please refer to K-0054 for additional information

15. The facility failed to maintain supervision of sprinkler system control valves. This condition may cause a valve to be inadvertently turned off, impacting the suppression systems capability in the event of a fire.
Please refer to K-0061 for additional information
16. The facility failed to ensure that the automatic fire sprinkler system was tested as required, installed and maintained as required, in accordance with NFPA 13 & 25. This renders the equipment unreliable, and in the event of a malfunction during a fire could delay or deny extinguishment.

Please refer to K-0062 for additional information

17. The facility failed to inspect the fire extinguishers as frequently as required, and maintain the extinguishers in reliable operating condition, in accordance with NFPA 101 and NFPA 10.

Please refer to K-0064 for additional information

18. Observations during tour of the facility, and interviews with the staff, it was determined that the facility failed to provide ashtrays of safe design in the designated outdoor facility smoking area in accordance with NFPA 101 19.7.4.

Please refer to K-0066 for additional information

29. During tour of Jackson Health System, it was determined that the facility failed to ensure the Ventilation System was maintained in reliable operating condition. This would promote unbalanced air pressure in the facility, promote sustained odors in the facility, and raise potential infection control issues in the facility.
Please refer to K-0067 for additional information

20. Observations during tour of the facility, it was determined that the facility failed to maintain the commercial cooking equipment in reliable operating safe condition, and to test the equipment in accordance with NFPA 96. This renders the equipment unreliable and could delay or deny extinguishment of a fire.

Please refer to K-0069 for additional information

21. Observations during tour of the facility, it was determined the facility failed to ensure that prohibited space heaters were in use, and to follow the facility policy regarding space heaters. Space heaters with elements which exceed 212 degrees Fahrenheit are prohibited in health care facilities.
Please refer to K-0070 for additional information

22. During tour of the facility, it was determined that the facility failed to ensure that the integrity of laundry and trash chutes are maintained in accordance with NFPA 82.
Please refer to K-0071 for additional information

23. During tour of the facility, it was determined that the facility failed to ensure that the exit access corridors were clear and unobstructed at all times, to full instant use in case of fire or other emergency. This in the event of fire or any reason to evacuate from a portion of the facility to another section or outside for an area of refuge may be delayed or denied as a result of exit corridor obstruction.

Please refer to K-0072 for additional information


24. During tour of Jackson Health System, a review of the facility records and interviews with the staff it was determined that the facility could not confirm the flammability ratings of the decorations in use in the facility in accordance with NFPA 101-2000 19.7.5.2, 19.7.5.3, 19.7.5.4. The facility personnel had no available verification that the decorations had been treated or were effectively flame retardant or flame resistant. With no available documentation, flame retardant labels, or purchasing records for the decorative plastic plants and moss-like substances, the flame retardant ratings could not be substantiated or confirmed.
Please refer to K-0073 for additional information

25. During tour of the facility, it was determined that the facility failed to ensure that non-medical flammable medical gas is handled and stored in accordance with NFPA 99. Unsecured oxygen cylinders have the potential if knocked over can rupture at the neck of the cylinder causing a super oxygen enriched atmosphere, increasing the flammability of all surrounding building contents, and the cylinder itself becoming projectile endangering all building occupants.

Please refer to K-0076 for additional information

26. During tour of the facility, it was determined that the facility failed to ensure that medical gas is handled and stored in accordance with NFPA 99.

Please refer to K-0077 for additional information

27. During tour of the facility, observations, interviews with the staff, and a review of the facility records, conducted during the survey of Jackson Health System, it was determined that the facility failed to maintain the fire/smoke dampers in reliable operating condition. This condition could place the lives of the occupants in smoke environment should a fire occur and the fire/smoke dampers failed to respond.

Please refer to K-0104 for additional information

28. Based on an observation, a defunct Life Safety system and its components have not been removed from the facility. The area of concern is the former roof top fire protection equipment for a Heliport landing pad at the East Tower.

Please refer to K-0130 for additional information

29. Observations during tour of the facility, and interviews with facility staff, the facility failed to adequately protect the building occupants from flammable and combustible liquids. The facility further failed to maintain fire protection and occupancy features necessary to minimize danger to life in accordance with NFPA 101-19.3.2, 10.3.5., and the NFPA 30 (Flammable Liquid Code).

Please refer to K-0135 for additional information

30. A review of the facility records, interviews with the staff, and observations made during tour of the facility, it was determined that the facility failed to provide documentation that all of the generators and ancillary equipment were tested and certified at an optimal state in accordance with NFPA 101 and NFPA 110 " Standard for Emergency and Standby Power Systems ". NFPA 110- 8.4.9: Level 1 EPSS shall be tested for the duration of its assigned class for at least 4 hours at least once within every 36 months. Reference: NFPA 110-Standard for Emergency and Standby Power Systems 8.3.8 "A fuel quality test shall be performed at least annually using tests approved by ASTM standards."

Please refer to K-0144 for additional information

31. A review of the facility records, and interview with the staff during the Fire Life Safety survey, it was determined that the facility failed to ensure that all electrical wiring and electrical equipment are properly installed, tested as frequently as required, and maintained in reliable operating condition, tested as frequently as required, and maintained in accordance with NFPA 101, and NFPA 70.

Please refer to K-0147 for additional information

32. Observations made during tour of the facility, and interviews with the staff, it was determined that the facility failed to correctly install mounted alcohol dispensers in accordance with NFPA 101- 19.3.2.7 and CFR 403.744.

Please refer to K-0211 for additional information
VIOLATION: QAPI Tag No: A0263
This Condition of Participation is not met based on the facilities Maintenance and hospital departments or services responsible for the hospital's buildings and equipment (both facility equipment and patient care equipment) failure to incorporate on-going Fire Life Safety/maintenance issues into the hospital's QAPI program and be in compliance with the QAPI requirements.
The hospital failed to incorporate identified deficiencies in physical environment and life safety into their housewide quality assessment and performance improvement program.


Findings include:


1. A review of the annual fire alarm certification reports for the main campus (0109)on 1/24/11 at 10am revealed that The last annual certification was conducted 2/16/10. This report includes a list of deficiencies noted during the inspection. There is a "corrected" ink stamp next to the deficiencies. There were a number of uncorrected deficiencies in these lists. When questioned the facilities director stated that he did not know if this meant they were not yet corrected. He then called the fire alarm technician, who works onsite year round and requested that he come to the conference room. The technician verified that these deficiencies remained uncorrected for all this time. The facilities director did not know why or how this could happen. The facilities director and the director of support services verified and acknowledged this issue, and did not know why these issues were not identified and resolved thru the monthly Quality Assurance Meetings.

2. The 2/16/10 deficiency report for the main campus (0109) indicated that Air Handling Unit 226 fails to shut down when a smoke detection alarm is initiated. This was not corrected.

3. The 2/16/10 deficiency report for the main campus (0109) indicated that after resetting the alarm from an initiation elevator 104 recalls and locks out. This was not corrected.

4. The 4/14/10 deficiency report for the main campus (0109) in the South wing Penthouse, Air Handling Unit 7 fails to shut down. This unit controls floors 3 thru 7. The facility Director stated that this was for infection control purposes due to 2 Isolation Rooms on the 4th floor. Further investigation revealed that the Isolation Rooms have independent exhaust systems and there was no infection control issue. The alarm deficiency report further stated that the alarm point contact was in place and functional, however the air handler was disconnected from it. The facility director came to the conclusion that he did not know why this was not connected and would have this fixed immediately. at 11:45 pm on 1/27/11 the facility staff and the Simplex technician demonstrated the Air Handler shut down. Upon activation of a smoke detector and a delay for reconfirmation the Air Handler again failed to shut down. at 1:15 pm another test was demonstrated where the shut down was successful and the issue was attributed to two wires in reverse polarity. This deficiency was not corrected for 8 months. Although the facility director informed the surveyor that the Air Handler was now connected, there was no follow thru to ensure correction. The surveyor request for demonstration is how the deficiency was identified as still non-functional.

5. The 9/16/10 report for the main campus (0109) Diagnostic Treatment Center stated that there was a smoke detector mounted to the ceiling above the escalator that is not a listed device in the system and is not connected to anything. Further investigation revealed that this is a smoke detector from an old alarm system and is not connected but was never removed. This was uncorrected.

6. The 9/16/10 report for the main campus (0109) Diagnostic Treatment Center stated that Air Handling Unit 263 failed to shut down on activation of the system. This was uncorrected.

7. The 8/27/10 report for the main campus (0109) Ryder Trauma Center stated that elevators 113 and 114 did not recall upon activation of the alarm, and failed to alternate floors on alarm activations that were applicable. The report further stated that this was not a alarm system problem, it was an elevator problem. The facilities director stated that he directed the elevator company to disconnect from the elevator recall programming because the elevator bank serviced the hospital secured unit for prisoners. This was uncorrected.

8. The 2/26/10 report for the main campus (0109) Rehabilitation Center indicated that elevators 291, 292, 293, and 294 all failed to recall when tested in conjunction with the alarm system. This was not corrected.

9. The 7/20/10 deficiency report for the main campus (0109) Central Building indicated that six audio alarm devices were disconnected from system. The facility director stated that this was due to the audio devices being installed in the neonatal unit. The devices were incapable of adjustment for sound level so they were disconnected. No adjustable audio replacements were installed. No equivalencies were sought.

10. The 7/20/10 deficiency report for the main campus (0109) Central Building indicated that there were three fire alarm panels that were not connected to dedicated power and circuit breakers. The alarm technician stated that this arrangement has remained for a number of years, however the wires were traced this year, with the current determination. This was uncorrected.

Interview of the Vice President of Quality, and review of the housewide quality program, on 1/26/11, there was no evidence of the enumerated physical environment and life safety code deficiencies incorporated into the housewide quality program for corrective measures and performance improvement. Review of the physical environment committee meeting minutes , on 1/28/11, did not contain identification of the deficiencies or plan to keep the physical environment in compliance.