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Based on surveyor review of the Emergency Preparedness Program Plan and interview with the Regional Facilities Director, the facility failed to develop, establish and maintain a comprehensive plan specific to the Middleboro Hospital site. This deficient practice could affect all patients, as well as an indeterminable number of staff and visitors.

The findings include:

During the morning hours of 11/26/18 while reviewing the Emergency Preparedness Program, and interview with the Regional Director of Facility's, the following items were observed regarding the development of the Emergency Preparedness Plans:

1. The Emergency Preparedness Program plans are generic in nature and not individualized to the Middleboro Hospital site. The Emergency Preparedness policies and procedures (P&P) manual which was made available for review has not been completed and customized to the Middleboro Hospital. The Regional Director of Facility's stated that the manual is a work in progress and acknowledged that many P&P's referred to in the plans are corporate generated and apply to the numerous facilities mainly located on the South Shore and Cape Cod areas. It was further stated that the P&P's needed to be reviewed for accuracy pertaining to this actual Hospital location.

2) In addition, the facility failed to conduct an annual review of the Emergency Preparedness Plans. The document regarding the annual review was observed to blank with no actual signatures and/or dates provided.

As a result of having a generic Emergency Preparedness Program Plan, the Hospital failed to develop, establish, and maintain a comprehensive emergency preparedness program for all of the required P&P pertaining to the Middleboro Hospital site.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on the Emergency Preparedness Plan review and interview with the Regional Director of Facility's, the Hospital failed to develop an emergency plan including a process for cooperation and collaboration with local, regional, tribal, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. This deficient practice could affect all patients, as well as an indeterminable number of staff and visitors.

THE FINDINGS INCLUDE:

During the morning hours of 11/26/18 while reviewing the Emergency Preparedness Program documentation, it was revealed that the Hospital did not have a policy and procedure (P&P's) for cooperation and collaboration with local, regional, tribal, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation and, when applicable, of its participation in collaborative and cooperative planning efforts. The Regional Director of Facility's stated that the manual was a work in progress and that some P&P's have not been developed and added to the emergency plans. As of survey date, this particular P&P had yet to be developed for this Middleboro Hospital site.

As a result of not having a P&P for cooperation and collaboration with local, regional, tribal, State and Federal emergency preparedness officials', the Hospital failed to comply with specific Emergency Preparedness development requirements.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on the Emergency Preparedness Plan review and interview with the Regional Director of Facility's, the Hospital failed to develop an emergency plan including a means to shelter in place the clients, staff, and volunteers who remain in the facility during an emergency situation. This deficient practice could affect all patients, as well as an indeterminable number of staff and visitors.

THE FINDINGS INCLUDE:

During the morning hours of 11/26/18 while reviewing the Emergency Preparedness Program documentation, it was revealed that the Hospital did not have a policy and procedure (P&P's) for the means of sheltering in place for clients, staff, and volunteers who remain in the facility during an emergency. The Regional Director of Facility's stated that the manual was a work in progress and that some P&P's have not been developed and added to the emergency plans. As of survey date, this particular P&P had yet to be developed for this Hospital.

As a result of not having a P&P for sheltering in place, the Hospital failed to comply with specific Emergency Preparedness development requirements.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on the Emergency Preparedness Plan review and interview the Regional Director of Facility's, the Hospital failed to develop an emergency communication plan complying with Federal, State and local laws. This deficient practice could affect all patients, as well as an indeterminable number of staff and visitors.

THE FINDINGS INCLUDE:

During the morning hours of 11/26/18 while reviewing the Emergency Preparedness Program documentation, it was revealed that the Hospital did not have a policy and procedure (P&P's) regarding a communication plan for how the Hospital coordinates patient care within the Hospital, across healthcare providers, and with state and local public health departments. The Regional Director of Facility's stated that the manual was a work in progress and that some P&P's have not been developed and added to the emergency plans. As of survey date, this particular P&P had yet to be developed for this Hospital.

As a result of not having a P&P for a communication plan for how the Hospital coordinates patient care within the Hospital, across healthcare providers, and with state and local public health departments, the Hospital failed to comply with specific Emergency Preparedness development requirements.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on the Emergency Preparedness Plan review and interview with the Regional Director of Facility's, the Hospital failed to develop, establish and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and is reviewed and updated at least annually. The communication plan must include all of the following:
(2) Contact information for the following:
(i) Federal, State, tribal, regional and local emergency preparedness staff.
(ii) Other sources of assistance.
This deficient practice could affect all patients, as well as an indeterminable number of staff and visitors.

THE FINDINGS INCLUDE:

During the morning hours of 11/26/18 while reviewing the Emergency Preparedness Program documentation, it was revealed that the Hospital did not have a policy and procedure (P&P's) including the contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance. The Regional Director of Facility's stated that the manual was a work in progress and that some P&P's have not been developed and added to the emergency plans. As of survey date, this particular P&P had yet to be developed for this Hospital.

As a result of not having a P&P for contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance, the Hospital failed to comply with specific Emergency Preparedness development requirements.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on the Emergency Preparedness Plan review and interview with the Regional Director of Facility's, the Hospital failed to develop, establish and maintain a comprehensive policy regarding the sharing of information with the Authority Having Jurisdiction (AHJ), the Incident Command Center, or designee. This deficient practice could affect all patients, as well as an indeterminable number of staff and visitors.

THE FINDINGS INCLUDE:

During the morning hours of 11/26/18 while reviewing the Emergency Preparedness Program documentation, it was revealed that the Hospital did not have a policy and procedure (P&P's) regarding information about the facility's occupancy, needs, and its' ability to provide assistance to Authority Having Jurisdiction (AHJ), the Incident Command Center, or designee for this Middleboro campus location. The Regional Director of Facility's stated that the manual was a work in progress and that some P&P's have not been developed and added to the emergency plans. As of survey date, this particular P&P had yet to be developed for this Hospital.

As a result of not having a P&P regarding information about the facility's occupancy, needs, and its' ability to provide assistance to Authority Having Jurisdiction (AHJ), the Incident Command Center, or designee, the Hospital failed to comply with specific Emergency Preparedness development requirements.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that all the buildings are of a conforming construction type. Table 19.1.6.2 requires buildings 4-stories in height or greater to be of at least Type I (443), Type I (332) or Type II (222).

THE FINDINGS INCLUDE:

During the morning hours of 11/27/18, it was observed that the original 2-story, 1936 building is of Type II (000) construction. After a review of the hospital supplied plans, it was noted that the original roof of the 1936 building was constructed of wood. The roof was removed during renovations and replaced in its' entirety with steel I-beams, steel joists, and metal pan decking. When the ceiling air diffusers were viewed for compliance in this location, it was revealed that the required fire dampers were not installed. In addition, although the recessed light fixtures were observed as being tented as required, numerous sections of the enclosures (tents) were observed to be loose and laying next to the light fixtures. As a result of the missing fire dampers and loose/missing tenting, the ceiling assembly is not protecting the steel roof structure as required for Type II (222) construction.

Although the 2nd floor of this 1936 building is used solely for administrative purposes, it is surveyed under healthcare regulations as it is not separated from the remaining portions of the hospital with a 2-hour fire barrier wall. Because there is not a 2-hour fire barrier wall between the original building and the remaining buildings, it is all considered one building. Therefore, the non-separated 2-story original 1936 building is down grading the construction classification of the remaining 4-story building.

As a result of the lack of 2-hour separation between the two different construction classifications, the 4-story building is no longer a complying construction classification as required by table 19.1.6.2. The building is required to be of at least a Type II (222) construction classification.

NOTE: The years of construction of the various buildings were noted as c1936, c1955, c1968 and c1979. There are no 2-hour fire walls between any of these buildings, therefore they were surveyed as one building.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that two approved egress routes from each compartment are provided as required.

Section 19.2.4.1 states the number of means of egress shall be in accordance with 7.4.1.1 and 7.4.1.3 through 7.4.1.6.

Section 19.2.4.4 states not less than two exits shall be accessible from each smoke compartment, and egress shall be permitted through an adjacent compartment(s), provided that the two required egress paths are arranged so that both do not pass through the same adjacent smoke compartment.

Section 19.2.2.3 states stairs complying with 7.2.2 shall be permitted.

Section 7.2.2.3.3.1 states stair treads and landings shall be solid, without perforations, unless otherwise permitted in 7.2.2.3.3.4

THE FINDINGS INCLUDE:

While surveying the facility during the morning hours of 11/27/18, it was observed that a fire escape is provided as an exit from the 2nd floor Administrative area. This area/compartment has one interior stairwell which is located just outside of the smoke barrier wall. However, the second exit is an exterior steel fire escape stair which has perforations of 1" x 3-3/4" in size. As noted above, fire escapes are not an approved means of egress.

As a result of the fire escape, the facility failed to comply with section 19.2.4.4 requiring two approved egress routes from each compartment.

NOTE: The Administrative compartment is surveyed under healthcare regulations as it is not separated from the remaining hospital with a 2-hour fire barrier wall.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on observations the facility failed to ensure that all hazardous areas are protected in accordance with the 2012 edition of NFPA 101 Life Safety Code.

-Chapter 19 Section 19.3.2.1 states any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
-Chapter 19 Section 19.3.2.1.1 states an automatic extinguishing system, where used in
hazardous areas, shall be permitted to be in accordance with 19.3.5.9.
-Chapter 19 Section 19.3.2.1.2* states where the sprinkler option of 19.3.2.1 is used, the
areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.
-Chapter 19 Section 19.3.2.1.3 states the doors shall be self-closing or automatic-closing.
-Chapter 19 Section 19.3.2.1.5 states hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

-Chapter 8 Section 8.4.3.1 states doors in smoke partitions shall comply with 8.4.3.2
through 8.4.3.5.
-Chapter 8 Section 8.4.3.2 states doors shall comply with the provisions of 7.2.1.

-Chapter 7 Section 7.2.1.8.1* states a door leaf normally required to be kept closed
shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
-Chapter 7 Section 7.2.1.8.2 states in any building of low or ordinary hazard contents,
as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria
are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door leaf becomes self-closing.

Findings Include:

While conducting the facility tour during the afternoon hours of 11/26/18 and the morning of 11/27/18, observations revealed that numerous hazardous areas were lacking self-closing devices on the doors.

The following locations but not limited to were observed as not having self-closing devices on the doors:

1st Floor:
IPU#1, Patient Property Room.
IPU#2, Oxygen Storage Room and Patient Property Room.

Basement:
Kitchen Paper Storage Room
Door # B2, Medical Records File Room
Door # B5, Clothing Donation Room

As a result of the findings, the facility is found to be non-compliant with Chapter 19 Section 19.3.2.1.3. Doors to hazardous areas must be self-closing or equipped with an automatic closing device compliant with Chapter 7 of the 2012 edition of NFPA 101 Life Safety Code.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke detectors are properly located in relation to the Heating Ventilating Air Conditioning (HVAC) System air diffusers.

Section 19.3.4.1 states health care occupancies shall be provided with a fire alarm system in accordance with section 9.6.

Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72 section 17.7.4.1 states in spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. (910 mm) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 11/27/18 while touring the facility, it was observed that smoke detectors are mounted directly adjacent (approximately one foot) to air diffusers in numerous locations throughout the facility. This was mainly observed in the Administrative area, but was also observed in each of the nursing units throughout the building.

As a result, the facility failed to comply with section NFPA 72 section 17.7.4.1 and the placement of smoke detecting devices in relation to HVAC diffusers.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained to resist the passage of smoke .

Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13.4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

Section 19.3.6.3.2 states the requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required to comply with 19.3.6.3.1.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 11/27/18 while touring the facility, it was observed that numerous patient rooms were equipped with barrier-resistant door units (Door within a door). These corridor door units consist of an inward swinging 36" solid core door with an outward swinging 15" x 60" inner door. The inner door is latched to the main door utilizing a keyed deadbolt operated from the corridor side of the door only. When viewing the doors for smoke resisting capabilities, a substantial gap on three edges of the inner doors were observed. These gaps which were observed ranged between 1/16" and 1/4" in size throughout the entire facility.

As a result, the facility failed to comply with section 19.3.6.3.2 requiring corridor doors to resist the passage of smoke.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that corridor walls are maintained to be smoke resistant. Section 19.3.6.2.3 states corridor walls shall form a barrier to limit the transfer of smoke.

Section 19.3.6.4.1 states transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 11/27/18, the following items but not limited to were observed regarding the construction of corridor walls within the facility:

1) An approximate 6" x 36" wall transfer grill was observed above the door of the Laundry Room on Unit 4.
2) An approximate 6" x 18" wall transfer grill was observed above the door of the Laundry Room on Unit 2.
3) An approximate 6" x 18" wall transfer grill was observed above the door of the Soiled Utility Room identified as door #136.
4) An approximate 6" x 18" wall transfer grill was observed above the door of the Electrical Closet identified as door #107.

As a result, the Hospital failed to comply with section 19.3.6.4.1 prohibiting the use of transfer grills in corridor walls and/or doors.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are maintained as required.

Section 19.3.7.6 states openings in smoke barriers shall be protected using one of the following methods:
(1) Fire-rated glazing
(2) Wired glass panels in steel frames
(3) Doors, such as 1-3/4 in. (44 mm) thick, solid-bonded woodcore doors
(4) Construction that resists fire for a minimum of 20 minutes.

Section 19.3.7.8 states doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 11/27/18 while touring the facility, the following items were observed regarding smoke barrier doors:

1) The smoke barrier door located at the Administrative area is equipped with an 11" x 11" non-rated piece of plexi-glass.

2) The Unit #2 Kitchenette door which is part of the smoke barrier assembly is not equipped with a self-closing device.

As a result, the facility failed to comply with section 19.3.7.6 and 19.3.7.8 requiring smoke barrier doors to have rated glazing and be self closing.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.

Based on observations and documentation review, the facility failed to ensure compliance with the 2012 edition of NFPA 99 Health Care Facilities Code.

NFPA 99 Chapter 6 Section 6.3.4.1.3 states receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Section 6.3.3.2.1 states the physical integrity of each receptacle shall be confirmed by visual inspection.

Section 6.3.3.2.2 states the continuity of the grounding circuit in each electrical receptacle shall be verified.

Section 6.3.3.2.3 states correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.

Section 6.3.3.2.4 states the retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Findings Include:

A review of life safety documentation conducted during the morning hours of 11/26/18 indicated that the non-hospital grade electrical receptacles located at patient bed locations (resident rooms) are not being tested annually as required.
When questioned, the facility's Maintenance Supervisor stated that he was unaware of the requirement.

As a result of the finding the facility is found to be non-compliant with NFPA 99 Chapter 6 Section 6.3.4.1.3.

This was confirmed by the Hospital Administrator, Regional Director of Facilities, and the Director of Facilities during the exit interview process.