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Based on record review and interview, the hospital failed to ensure development, maintenance, and annual review of a facility-based community-based risk assessment using an all hazards approach as required.

Findings:

Record review of the emergency preparedness plan dated 2016 showed the facility did not annually maintain and review the facility-based and community-based risk assessments that utilized an all hazards approach. An annual risk assessment for the facility emergency preparedness plan did not exist for 2017.

On 06/19/18 at 11:17 am, the surveyor asked Staff A and Staff D for written documentation of the facility's risk assessments and associated emergency preparedness strategies. Staff A stated the risk assessment had not been updated annually since 2016. The documentation did not exist.

Based on record review and interview, the hospital failed to develop strategies for addressing and identifying the needs of at risk or vulnerable patient population during an emergency event or disaster.

Findings:

Record review of the emergency preparedness plan showed the facility did not develop or identify the facility's patient populations that would be at risk during an emergency event.


On 06/20/18 at 10:17 am, the surveyor asked Staff A if the facility identified and addressed the types of services the facility would be able to provide in an emergency. Staff A stated the facility was unaware the emergency plan needed to address the patient populations that would be at risk during an emergency event. The documentation did not exist.

Based on record review and interview, the hospital failed to include a process for cooperation and collaboration with local, Tribal, Regional, State, and Federal emergency preparedness officials' including documentation of the facility's efforts to contact such officials.

Findings:

Record review of the emergency preparedness plan dated 2018 showed the facility did not document their efforts to contact and ensure cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' in order to ensure integrated responses during disaster or emergency.


On 06/18/18 at 11:33 am, the surveyor asked Staff A if the facility documented efforts made to contact emergency preparedness officials to engage in participation and collaborative planning efforts. Staff A stated the facility had not participated in or documented the cooperation or collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' to ensure integrated response during a disaster or emergency situation. Staff A stated the facility treated psychiatric patients only, the surveyor stated the facility is licensed as an hospital and this requirement was part of the emergency preparedness plan. Staff A stated the documentation did not exist.

Based on record review, observation, and interview the facility failed to ensure staff were trained on the procedures for the facility tracking system of staff and patients.

Findings:

Record review of Staff V and Staff W facility training records for emergency preparedness did not show verification the facility staff received training on the patient tracking system procedures used by the facility. The staff training documentation did not exist.

On 06/20/18 at 10:15 am the surveyor interviewed two nursing facility staff (nurse Staff V, nurse Staff W) were asked about the facility's tracking system. Nurse Staff V and nurse Staff W were unable to describe and demonstrate the patient tracking system. The facility failed to establish a triage system used to track patients by the facility of staff and patients.

Based on record review and interview, the hospital failed to ensure the emergency preparedness policies and procedures identified a system of medical documentation preserving the patient information, protecting confidentiality of patient information.

Findings:

Record review of the emergency disaster plan policies and procedures revealed the facility did not establish and maintain a medical record documentation system in order to preserve patient information, protects the confidentiality and secure patient information.

On 06/20/2018, the surveyor asked Staff A if the facility had a plan in place to address if an disaster would affect the facility and evacuation occurs how the patients medical records
would ensure confidentiality was protected and secured. Staff A stated the medical records will be evacuated with the patients. The surveyor informed Staff A the facility policies and procedures should be in compliance with the Health Insurance Portability and Accountability Act (HIPPA), Privacy and Security Rules at 45 CFR parts 160 and 164. The policy and procedure did not exist.

Based on record review and interview the facility failed to ensure the development of written transfer agreements or contracted agreements with other facilities identified in their emergency procedure manual to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Findings:

Record review showed the facility did not ensure written or memorandums of understanding and transfer agreements were established with Integris Bass Hospital located across the street from the facility.

On 06/20/18 at 1:17 pm the surveyor asked Staff A for documentation of transfer agreement or contracted arrangements to receive patients in the event of an disaster and transfer patients from the facility. Staff A stated the facility would transfer their patients to Integris hospital located across the street from the facility. Staff A stated the prearranged or memorandum of understanding written transfer agreement did not exist with Integris Bass Hospital.

Based on record review and interview, the hospital failed to ensure the emergency preparedness policies and procedures addressed the facility's role in emergencies where the President declares a major disaster.

Findings:

Record review of the emergency preparedness policies and procedures showed the facility did not establish and maintain an policy and procedure in the emergency plan describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

On 6/20/2018, the surveyor asked Staff A, for the facility policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff A stated the facility had not developed a policy. The document did not exist.

Based on record review and interview the facility failed to ensure an emergency preparedness communication plan included contact information for Federal, State, Tribal, regional, and local emergency preparedness staff.

Findings:

Record review of the emergency preparedness plan dated 2018 showed the facility did not develop an communication plan that included contact information with local, Tribal, Regional, State, and Federal emergency preparedness staff.


On 06/19/18 at 11:33 am, the surveyor asked Staff A if the facility included contact information for emergency preparedness staff. Staff A stated the facility had not created contact information in the communication plan for local, tribal, regional, State, and Federal emergency preparedness Staff. The facility would start working on and gathering the contact information. The contact documentation did not exist.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that addressed the means in the event of an evacuation, to release patient information to include the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).

Findings:

Record review of the facility emergency preparedness communication plan did not contain methods for sharing information and medical documentation for patients under the facility's care with other health care providers to maintain continuity of care in the event of an evacuation as required.

On 06/20/18 at 1:33 pm the surveyor asked Staff A for documentation to verify the facility had developed an emergency preparedness communication plan. The communication plan should include how the facility would share information for patients under the facility's care as necessary with other heath care providers in the event of an emergency. Staff A stated they were unaware of this requirement and had not developed an emergency preparedness communication plan that included sharing information. The Staff A stated the facility would develop a plan to address sharing information in the event of an evacuation.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that provides information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, Incident Command Center, or designee.

Findings:

Record review of the facility emergency preparedness communication plan did not contain the facility's means of providing information concerning occupancy, needs and its ability to provide assistance to the authority having jurisdiction.

On 06/21/18 at 11:33 am the surveyor asked the Staff A for documentation to verify the facility had developed an emergency preparedness communication plan means of how the facility would provide information about the facility's occupancy, needs, and ability to provide assistance. Staff A stated they were unaware of this requirement and had not developed an emergency preparedness communication plan to address occupancy or ability to provide assistance to the authority having jurisdiction, Incident Command Center, or designee. Staff A stated the facility would develop a plan to address facility's occupancy. The documentation did not exist.

Based on record review and interview the facility failed to ensure annual and initial in-service training for staff, and individuals providing services under arrangement, on the emergency preparedness plan for six (staff AA , staff BB , staff D, staff X, staff Y, and staff Z ) of 28 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for existing staff, and individuals providing services under arrangement for the following staff:

Staff X with the date of hire 08/01/11, had not received initial or annual in-service training for emergency preparedness plan.

Staff AA with the date of hire 11/15/99 had not received initial or annual in-service training for emergency preparedness plan.

Staff Z with the date of hire 02/03/17 had not received annual in-service training for emergency preparedness plan.

Staff Y with the date of hire 09/17/97 had not received annual in-service training 1999-2017 for emergency preparedness on the facility emergency preparedness plan.

Staff D with the date of hire 07/28/14 had not received annual in-service training for emergency preparedness plan.

Staff BB with the date of hire 01/29/01 had not received initial or annual in-service training for emergency preparedness plan.

The emergency preparedness training records for initial and or annual in-service do not exist for Staff AA, Staff BB, Staff D, Staff X, Staff Y and Staff Z.

On 06/19/18 at 11:15 am the surveyor asked Staff E, and Staff A for documentation of training in-service for new, existing staff members, and individuals providing services under arrangement/contract. The emergency preparedness training documentation does not exist.

Based on record review and interview the facility failed to demonstrate education and instruction to staff, contractors, and facility volunteers.


Record review of the facility emergency preparedness training documentation did not show documentation of the tabletop exercise, community based exercise, or full-scale exercise to demonstrate staff knowledge of emergency procedures because the documentation did not exist for drills and or exercises to test the emergency plan identifying gaps and areas for improvement.

On 6/20/18 at 10:15 am surveyor requested the Staff A for documentation such as a sign-in sheet, meeting minutes, to verify staff received training on drills or exercises completed by the facility. Staff A stated the facility did not participate or conduct an Tabletop, individual based or community based training for 2016, 2017. The facility was unaware the training was required because they are a mental health psychic facility. The surveyor stated the facility is licensed as an hospital and is surveyed under the guidelines for the emergency preparedness. The document did not exist.

Record review of the facility emergency preparedness training Willow Crest Hospital is part of a Integrated healthcare system, Moccasin Bend Ranch. The facility is operating under a separate CMS number. The facility failed to demonstrate they actively participated in the development of the unified and integrated emergency preparedness program. The documentation did not exist.

Findings:

The following facility policy and procedures did not provide evidence the policy was specific to the hospital and approved by the governing board:
~Environment of Care Maintenance Plan
~Fire Safety Emergency Codes
~Policies and Procedures for Emergency Electrical Generator
~Policies and Procedures for External Disaster
~Policies and Procedures for Electrical Safety and Testing

On 6/21/2018 at 10:25 am, the surveyor asked the Staff A for for the policies specific to the facility and documentation the facility actively participated in the development of the unified and integrated emergency preparedness program. Staff A stated she was unaware of this requirement. Staff A stated the facility combined the policies for both Willow Crest Hospital and Moccasin Bend Ranch. The surveyor stated the emergency preparedness policies should be specific to the hospital operating under a different CMS CCN number. Staff A stated the facility would work on the requirements to make the policy specific to Willow Crest Hospital and at this time the documentation did not exist.

Based on observation and interview the facility failed to ensure aisles, passageways, corridors, exit discharges, exit locations, accesses, and the means of egress are continuously maintained free of all obstructions to full use in case of emergency.

Findings:

On 06/19/18 at 10:06 am a three seat wooden sofa chair was observed to be placed directly against a designated exit access door blocking access to the exit corridor.

On 06/19/18 at 10:06 am Staff D said he did not know where the three seat sofa came from but will move it away from blocking the door and will tell staff not to block any exit door.

On 06/19/18 at 3:46 pm an exit access corridor door located in the latency department staff room was observed to be blocked from being able to be fully opened due to a shredding container having been placed within a few feet of the door hinge.

On 06/18/18 at 3:55 pm the surveyor asked Staff D why the shredding box was so close to the exit access door. Staff D stated he did not know but would find another location so it will not block any exit path.

Based on observation and interview the facility failed to ensure barrel latches were not installed within the facility and to have on all exit access doors a positive latching locking device which opens with only one action.

Findings:

On 06/19/18 at 9:54 am the surveyor observed a barrel latch and deadbolt on the storage room door near the front reception desk.

On 06/19/18 at 9:54 am the surveyor asked Staff D why the barrel latch was on the door and he stated he did not know why. Staff D stated the barrel latch would be taken off.

On 06/19/18 at 10:05 am a keyed deadbolt and a deadbolt with a turn knob was observed to be installed on the exit access corridor door to the facility's front office conference room.

On 06/19/18 at 10:05 Staff D was asked why there were two deadbolts on the exit access corridor door. He stated he did not know but will take care of the deadbolts. The surveyor explained it would take more than one action for a person to gain access to the exit corrdior from inside the conference room.

Based on observation and interview the facility failed to ensure each emergency exit discharge area was provided with emergency powered lighting.

Findings:

On 06/20/18 at 2:04 pm the surveyor observed each of the facility's nine emergency exit discharges did not have battery backed up emergency powered lighting or generator wired emergency powered lighting.

On 06/20/18 at 2:04 pm Staff D stated he will install emergency powered battery backed up lighting at each of the nine exit discharges or have emergency exit discharge lighting wired to the emergency generator at each of the nine exits of the facility in order to meet compliance.

Based on observation and interview the facility failed to ensure a hazardous area was properly protected/separated from other use spaces.

Findings:

On 06/20/18 at 3:12 pm the surveyor observed a room on the outside wall of the group craft room. The enclosed closet space was observed to contain flammable corrugated boxes of HVAC filters, a fire cabinet with flammable liquids, and two 5 gallon buckets of floor stripper, and a portable handheld work light clipped onto a board above the flammable liquids cabinet. Two exhaust fans were observed at each end of the closet space. One exhaust fan was in the right side of the closet which drew air out of the group craft class room and created an opening which would allow fire/smoke into the classroom. The second exhaust fan created an opening which would allow fire/smoke to spread into the other room. The surveyor observed two extension cords coming into the closet from each of the rooms. The surveyor observed a fire sprinkler head with white paint on head of the sprinkler.

On 06/20/18 at 3:13 pm Staff D was asked why the fire cabinet was in a non-protected storage area. He stated he was not aware of the contents of the storage closet but will find an appropriate protected storage location for the hazardous items.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 06/20/18 at 9:40 am a K class fire extinguisher was observed in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher.

On 06/20/18 at 9:40 am Staff D stated he would get with their fire service vendor to get the appropriate placard(s) for each of the fire extinguihsers that are installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview the facility failed to ensure the automatic sprinkler systems are inspected, and maintained in accordance with NFPA 25.

Findings:

On 06/20/18 at 9:37 am several sprinkler heads over the large freezers in the kitchen were observed to have lint on them.

On 06/20/18 at 9:57 am a high temperature sprinkler head installed over a water heater in the washer and dryer closet was observed to be corroded.

On 06/20/18 at 10:17 am a high temperature sprinkler head was observed to have paint on the deflector and the head was located in a built in storage closet with outside access.

On 06/20/18 at 10:17 am the surveyor stated condition of the sprinkler heads should be included on the sprinkler inspections. Staff D stated he has only been in his position for three weeks but would make sure sprinkler heads are on the check list for their fire service vendor from this point on.

Based on observation and interview the facility failed to ensure smoke barriers were smoke resistant.

Findings:

On 06/19/18 at 10:01 am penetrations were observed in the ceiling tiles located in the front hallway near the CEO's office which would allow fire and smoke to spread into throughout the facility. A sprinkler head in the front hallway was observed without its escutcheon which would allow smoke and fire spread into the plenum space.

On 06/19/18 at 10:16 am two ceiling tiles were observed to be out of place in the DON's office, and the medical closet in the DON's office had a ceiling tile missing which would allow fire and smoke to spread throughout the facility.

On 06/19/18 at 10:34 am seven holes were observed in the ceiling tiles in the group television room.

On 06/19/18 at 11:15 am a penetration was observed in the ceiling of the clean linen storage closet located by patient room #16.

On 06/19/18 at 2:56 pm six penetrations were observed in the wall of the electrical closet in addition to having flammable items stored within the area.

On 06/19/18 at 3:10 pm four penetrations were observed in the wall of the mechanical room housing the boiler.

On 06/19/18 at 3:10 pm the surveyor asked Staff D why the penetrations are not filled throughout the facility. Staff D stated he is in his third week of employment and is getting maintenance schedules setup to which a penetration preventative maintenance program will be followed up on.

Based on observation and interview the facility failed to ensure barrel latches were not installed within the facility.

Findings:

On 06/20/18 at 8:58 am the surveyor observed a barrel latch on the storage room door near the front reception desk.

On 06/20/18 at 9:00 am the surveyor asked Staff D why the barrel latch was on the door and he stated he did not know why. Staff D stated the barrel latch would be taken off.

Based on observation and interview the facility failed to ensure facility electrical
wiring and equipment was in accordance with the National Electrical Code.

Findings:

On 06/19/18 at 9:58 am a refrigerator was observed to be plugged into a power tap in the front office and in the CEO's office.

On 06/19/18 at 9:58 am Staff D stated he would plug the refrigerators directly into a grounded wall electrical outlet.

On 06/19/18 at 10:12 am a microwave was observed to be plugged into a power tap.

On 06/19/18 at 10:12 am Staff D stated he would remove the power tap and plug the microwave directly into the wall electrical outlet.

On 06/19/18 at 10:20 am a medical refrigerator located in the DON's closet was observed to be plugged into a power tap.

On 06/19/18 at 10:22 am Staff D stated he would remove the power tap.

On 06/19/18 at 10:28 am an extension cord was observed to be in use which had a 4 outlet multiplug placed on the end of it with an electric pencil sharpener plugged into it in the classroom.

On 06/19/18 at 10:30 am Staff D stated he would remove the extension cord and multiplug.

On 06/19/18 at 11:44 am two piggy backed extension cords were observed plugged into a florescent light located in the group craft room.

On 06/19/18 at 11:45 am Staff D stated he would remove the the extension cords from the craft room.

On 06/20/18 at 10:16 am two extension cords were observed in an outside access storage closet.

On 06/20/18 at 10:16 am the surveyor asked Staff D why the two extension cords are being used. Staff D stated he did not know why. Staff D stated he will remove the extension cords and power taps from the facility where they do not meet compliance.

On 06/21/18 at 11:20 am a open junction box was observed in the plenum space near the electrical closet near the cafeteria.

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2017 were not completed and the documentation did not exist.

On 06/18/18 at 12:35 pm the surveyor asked Staff D for the annual fire rated door assembly inspections. Staff D stated the inspection was not completed for 2017 and the documentation did not exist.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed.

On 06/18/18 at 11:23 am during record review the surveyor asked Staff D for the EES and Medical Gas building system risk assessments, and Staff D he has only been in his position for three weeks so to his knowledge the building system risk assessments were not done.

Based on record review and interview the facility failed to ensure the emergency generator testing was completed.

Findings:

Record review showed the following not to have been completed: annual two hour emergency generator load bank testing for 2015, 2016, 2017, the 36 month four hour emergency generator load bank test, the May 2018 thirty minute load bank test.

On 06/18/18 at 1:52 pm Staff D was asked to provide the emergency generator log documentation for 2015, 2016 and 2017. Staff D stated the generator logs he already gave the surveyor was all he could find.