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Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency in accordance with 42 CFR 482.15(b)(6). This deficient practice could affect all occupants.

Findings include:

Based on record review on 07/16/18 between 9:45 and 11:45 a.m. with the Director of Plant Operations, the facility had an emergency preparedness plan, but it was incomplete. The emergency preparedness plan failed to ensured emergency preparedness policies and procedures include the use of volunteers in an emergency or other emergency staffing strategy, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency. Based on interview at the time of record review, the Director of Plant Operations acknowledged that the facilities emergency preparedness plan failed to ensure emergency preparedness policies and procedures include the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency. During the exit conference on 07/17/2018 at 11:45 a.m. with the Director of Plant Operations and the Regional Facilities Director, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include the role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials in accordance with 42 CFR 482.15(b)(8). This deficient practice could affect all occupants.

Findings include:

Based on record review on 07/16/18 between 9:45 and 11:45 a.m. with the Director of Plant Operations, the facility had an emergency preparedness plan, but it was incomplete. The facility failed to ensure the emergency preparedness policies and procedures include the role of the Hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. Based on interview at the time of record review, the Director of Plant Operations acknowledged the facility failed to ensure emergency preparedness policies and procedures include the role of the Hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. During the exit conference on 07/17/2018 at 11:45 a.m. with the Director of Plant Operations and the Regional Facilities Director, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least annually in accordance with 42 CFR 482.15(d). This deficient practice could affect all occupants.

Findings include:

Based on record review on 07/16/18 between 9:45 and 11:45 a.m. with the Director of Plant Operations, the facility had an emergency preparedness plan, but it was incomplete. The facility failed to develop and maintain an emergency preparedness training and testing program. Based on interview at the time of record review, the Director of Plant Operations acknowledged the facility failed to develop and maintain an emergency preparedness training and testing program. During the exit conference on 07/17/2018 at 11:45 a.m. with the Director of Plant Operations and the Regional Facilities Director, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The Hospital must do all of the following: (i) participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the Hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospital is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event; (ii) conduct an additional exercise that may include, but is not limited to the following: (A) a second full-scale exercise that is community-based or individual, facility-based. (B) a tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan; (iii) analyze the Hospital's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the Hospital's emergency plan, as needed in accordance with 42 CFR 482.15(d)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review on 07/16/18 between 9:45 and 11:45 a.m. with the Director of Plant Operations, the facility had an emergency preparedness plan, but it was incomplete. The facility failed to conduct a full-scale exercise to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. Based on interview at the time of record review, the Director of Environmental Services acknowledged that the Hospital failed to conduct a full-scale exercise. During the exit conference on 07/17/2018 at 11:45 a.m. with the Director of Plant Operations and the Regional Facilities Director, no additional information or evidence could be provided contrary to this deficient finding.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of over 5 hazardous areas, such as a room used for storage of combustible items and was over 50 square feet, was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect visitors and staff on east hall.

Findings include:

Based on observation on 07/16/18 at 1:40 p.m. with the Director of Plant Operations, the storage room on east hall had 18 cardboard boxes and measured 128 square feet and did not have a closing device on the door to automatically allow the door to close and latch into its frame. Based on interview with the Director of Plant Operations concurrent with the observation it was acknowledged the door to the storage room was determined to be a hazardous area and the door was not equipped with a closing device.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 2010 Edition, Section 14.4.5 requires testing shall be performed in accordance with Table 14.4.5 Testing Frequencies. NFPA 72, Table 14.4.5 at 15(a) and 15(h) states duct detector initiating devices shall be functional tested annually. Section 14.6.2.4 states a record of all inspections, testing and maintenance shall be provided that includes all applicable information requested in Figure 14.6.2.4. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Tyco SimplexGrinnell 's "Duct Detector Devices Results Summary" and "Inspection Summary" documentation dated 05/09/18 with the Regional Facilities Director and the Director of Plant Operations during record review from 9:45 a.m. to 3:30 p.m. on 07/16/18, 21 of 76 duct detectors were listed as "Failed" annual functional testing. Additional duct detector functional testing documentation within the most recent twelve month period was not available for review and repair or replacement documentation of the 21 duct detectors on or after 07/16/18 was also not available for review. Based on interview at the time of record review, the Director of Plant Operations stated the facility switched fire alarm system contractors within the last year and the new contractor did not feel it was safe to test the 21 duct detectors due to height or inaccessibility even though the former contractor tested the detectors as evidenced by Esco Communications "Sensitivity Testing" documentation dated 05/25/17. Esco Communications submitted a quote to retest the 21 duct detectors as evidenced by "Annual Fire Alarm Inspection (Duct Detectors Only)" and "Purchase Order" documentation dated 06/05/18 but the date for retesting could not be confirmed other than the estimated date of 07/30/18 as stated in Esco's e-mail to the facility on 07/09/18. Based on interview at the time of the exit interview at 11:45 a.m. on 07/17/18, the Regional Facilities Director and the Director of Plant Operations agreed duct detector functional testing on or after 05/09/18 had not yet been performed.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of patient indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of "Fire Plan: Plant Operations" documentation with the Regional Facilities Director and the Director of Plant Operations during record review from 9:45 a.m. to 3:30 p.m. on 07/16/18, the fire watch plan for a fire alarm system impairment was incomplete. The plan failed to include contacting the Indiana State Department of Health via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. In addition, the written fire watch did not include notification of the fire alarm system monitoring company and the building owner. Based on interview at the time of the exit interview at 11:45 a.m. on 07/17/18, the Regional Facilities Director agreed fire watch documentation for the fire alarm system impairment did not state to contact the Indiana State Department of Health via the ISDH Gateway link or at the e-mail address listed above and also did not include notification of the aforementioned two entities.

1. Based on record review and interview, the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of Koorsen Fire & Security "Inspection & Test Report" documentation dated 12/07/17 and Johnson Controls "Waterflow Alarm Inspection and Testing" documentation dated 06/04/18 with the Regional Facilities Director and the Director of Plant Operations during record review from 9:45 a.m. to 3:30 p.m. on 07/16/18, monthly wet sprinkler system gauge inspection documentation for ten months of the most recent twelve month period was not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for ten months of the most recent twelve month period was also not available for review. Based on interview at the time of record review, the Director of Plant Operations stated the facility has wet sprinkler systems and facility staff frequently conduct visual inspections of sprinkler system gauges and valves in addition to the semi-annual inspections performed by sprinkler system contractors but agreed monthly sprinkler gauge and system control valve inspections are not documented by the facility outside of the two contractor inspections performed within the most recent twelve month period.

2. Based on record review and interview, the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Koorsen Fire & Security "Inspection & Test Report" documentation dated 12/07/17 and Johnson Controls "Waterflow Alarm Inspection and Testing" documentation dated 06/04/18 with the Regional Facilities Director and the Director of Plant Operations during record review from 9:45 a.m. to 3:30 p.m. on 07/16/18, quarterly sprinkler system waterflow alarm inspection documentation for two calendar quarters in the most recent twelve month period was not available for review. Johnson Controls 06/04/18 inspection documentation indicated the facility has wet sprinkler systems and the "Frequency Method" of inspection was per "Section 5.3.3.2" of NFPA 25. Based on interview at the time of record review, the Director of Plant Operations stated the facility has vane-type waterflow alarm devices for the wet sprinkler system and facility staff frequently conduct visual inspections of sprinkler system gauges and valves in addition to the semi-annual inspections performed by sprinkler system contractors but the facility does not inspect waterflow alarm devices outside of the two documented contractor inspections performed within the most recent twelve month period.

3. Based on record review and interview, the facility failed to ensure the sprinkler system was maintained in accordance with NFPA 25. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system. Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Johnson Controls "Valve Tamper Switch Inventory" and "Fire Protection Systems Deficiencies" documentation dated 06/04/18 with the Regional Facilities Director and the Director of Plant Operations during record review from 9:45 a.m. to 3:30 p.m. on 07/16/18, the "#2 Backflow Shutoff Valve Tamper did not report to panel" and failed testing. Based on interview at the time of record review, the Director of Plant Operations stated the facility has a contractor to repair the backflow tamper but it had not been corrected at the time of the survey.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed for the protection of all residents in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Plan: Plant Operations" documentation with the Regional Facilities Director and the Director of Plant Operations during record review from 9:45 a.m. to 3:30 p.m. on 07/16/18, the fire watch plan for sprinkler system impairment was incomplete. The plan failed to include contacting the Indiana State Department of Health via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. In addition, the written fire watch did not include notification of the fire alarm system monitoring company and the building owner. Based on interview at the time of the exit interview at 11:45 a.m. on 07/17/18, the Regional Facilities Director agreed fire watch documentation for sprinkler system impairment did not state to contact the Indiana State Department of Health via the ISDH Gateway link or at the e-mail address listed above and also did not include notification of the aforementioned two entities.

Based on observation and interview, the facility failed to inspect 1 of 1 portable fire extinguishers in the Education room. NFPA 10, Standard for Portable Fire Extinguishers, Section 7.2.1.2 says Fire extinguishers shall be inspected either manually or by means of an electronic device / system at a minimum of 30-day intervals. This deficient practice could affect staff only.

Findings include:

Based on an observation with the Director of Plant Operations on 07/16/18 at 1:26 p.m., the monthly inspection tag on the fire extinguisher located in the Education room lacked a monthly inspection for the month of June, 2018. The lack of a monthly inspection for the month of June 2018 was acknowledged by the Director of Plant Operations at the above mentioned time of observation. During the exit conference on 07/17/2018 at 11:45 a.m. with the Director of Plant Operations and the Regional Facilities Director, no additional information or evidence could be provided contrary to this deficient finding.

Based on observation and interview, the facility failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms for 1 of 1 Wound care offices. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment to be installed in accordance with NFPA 90A, the Standard for the Installation of Air Conditioning and Ventilating Systems. NFPA 90A, Section 4.3.12.1.1 states egress corridors in nursing and long term care facilities shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.3.1 through 4.3.12.1.3.4. This deficient practice could affect only staff and visitors.

Findings include:

Based on observation on 07/16/18 during a tour of the facility from 1:10 p.m. to 3:00 p.m. with the Director of Plant Operations the Wound care office had a supply air duct in the room, but was using the egress corridor as a return air system. Based on interview at the time of the observation, the Director of Plant Operations acknowledged the Wound care office did not have a return in the room, but rather used to corridor as a return air plenum.

Based on record review, observation and interview; the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
This deficient practice could affect over two staff and visitors in the vicinity of the kitchen.

Findings include:

Based on review of "Fire Plan: Plant Operations" documentation with the Regional Facilities Director and the Director of Plant Operations during record review from 9:45 a.m. to 3:30 p.m. on 07/16/18, the written fire safety plan did not address the use of the K Class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. Based on observations with the Regional Facilities Director at 3:00 p.m. on 07/16/18, one K Class fire extinguisher was noted in the kitchen below a red placard stating to use the fire extinguisher only after activation of the kitchen range hood fire suppression system. Based on interview at the time of record review, the Director of Plant Operations agreed the written fire safety plan did not address the use of the K Class fire extinguisher in the kitchen.

Based on observation, testing and interview, the facility failed to ensure 4 of 9 ground fault interrupters (GFI) tested were functioning properly. This deficient practice could affect only staff or visitors in the Education room or Radiology.

Findings include:

Based on observations and testing on 07/16/18 during the tour between 1:00 p.m. to 3:00 p.m. with the Director of Plant Operations the GFI located in the Education room when tested and tripped could not be reset. In addition, three GFI's located in the darkroom of Radiology had three GFI's which simply had no power supply and would not work. The Director of Plant Operations tried to research potential reasons for this anomaly, but without result. Based on interview concurrent with the observations with the Director of Plant Operations it was acknowledged the aforementioned GFI's were defective and needed to be replaced.

Based on observation and interview, the facility failed to ensure 1 of 4 surge protectors observed were not used as a substitute for fixed wiring. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. LSC Section 4.5.7 states any building service equipment or safeguard provided for life safety shall be designed, installed and approved in accordance with all applicable NFPA standards This deficient practice could affect only staff and visitors.

Findings include:

Based on observation on 07/16/18 during the tour between 1:20 p.m. to 3:30 p.m. with the Director of Plant Operations a microwave was plugged into a surge protector in the Maintenance room. In addition, the Case Management office a two surge protectors piggybacked to each other used for various electrical appliances. Based on interview at the time of observations with the Director of Plant Operations it was verified and acknowledged a surge protector was used to power a microwave and two surge protectors were used in tandem and both instances were not allowed in the facility.