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Based on emergency preparedness documentation review and staff interview, the facility did not ensure:
(a) Its emergency preparedness (EP) program addressed its integrated EP plan. Reference is made to the lack of documentation.
(b) The Food and Nutrition Department develop a comprehensive emergency preparedness manual.

Review of facility Emergency Preparedness
Findings include:

Review of the Facility's Emergency Preparedness Plan revealed that the Emergency Preparedness Policies did not demonstrate whether the Specialty Hospital Emergency Preparedness Plans were integrated with the Skilled Nursing Facility's plan.

The Emergency Preparedness Plan failed to:

(1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program.

(2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered.

(3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance with the program.

(4) Include a unified and integrated emergency plan. The unified and integrated emergency plan must also be based on and include the following:

(i) A documented community-based risk assessment for each facility, utilizing an all-hazards approach.

(ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach.

(5) Include integrated policies and procedures.

There was no documentation provided to address these missing components.

Upon interview of the Vice President Facilities Management, Staff Bb on 11/05/21 at approximately 2:15 PM, confirmed that the Emergency Preparedness plan was not specific to the Specialty Hospital and its patient population and stated that corrections will be made.B. Emergency Preparedness


Food and Nutrition Department:

Review of facility Emergency Preparedness Manual noted the manual was approximately 1 ½ inch thick:
The manual is not user friendly for an employee that does not work in food service if assigned to prepare breakfast and is difficult to navigate.
There is no hand washing instruction in the manual.
There is no diagram of where food items are located.
The Menu provided had no portion size.
The manual is incomplete.

Based on observation and staff interview, the facility provided critical care areas where 16 patients were placed on ventilators and did not provide a conforming Type 1 Essential Electrical System (EES).

Findings include:

Review of the labeling of the circuit breakers on the 2 electrical panels (EC-E 06 and ELP-E3) served by the generator revealed that the loads were mixed and not separated by Life Safety, Critical and Equipment.
For example: On review of panel Elp-E3 circuit breakers, it was noted that pantry microwave and Pantry Refrigerator receptacles and the Medical Gas Alarm panel were served by the same panel.

Interview of the Director of Facilities, Staff C, on 11/04/21 at approximately 12:00 noon confirmed that even though the generator had 3 transfer switches, facility's EES did not have the 3 branches and that the loads were wired to one branch of EES.

This arrangement of electrical wiring to emergency powered receptacles and devices poses a potential injury and harm to patients.