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Based on document review and interview, it was determined the facility failed to develop a complete Emergency Preparedness Plan, affecting the entire facility.
Findings include:
1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to establish and maintain a comprehensive emergency preparedness program that was based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to maintain a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation that the Emergency Preparedness Plan address patient/client population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to develop a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to ensure documentation was available that includes a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to develop a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, revealed the facility failed to provide documentation for an emergency plan for subsistence needs for staff and patients whether they evacuate or shelter in place.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to provided a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation for an Emergency Preparedness Plan for safe evacuation from the facility, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to develop a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation of policies and procedures for a means to shelter in place of patients, staff, and volunteers.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to develop a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation on policies and procedures that included the development of arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to the facility.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to develop a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation that an emergency preparedness communication plan that complies with Federal, State and local laws was developed.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to develop a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation on emergency policies and procedures that included primary and alternate means for communicating with Facility staff, Federal, State, tribal, regional, and local emergency management agencies.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to develop a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation of an emergency plan that includes a means for providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, an Incident Command Center, or designee.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to provide a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation for an emergency preparedness training and testing program, of risks identified, based on the emergency plan.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on document review and interview, it was determined the facility failed to provided a complete Emergency Preparedness Plan, affecting the entire facility.

Findings include:

1. Review of documentation on March 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed the facility failed to provide documentation of the initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role; and provide documentation of annual emergency preparedness training.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the Emergency Preparedness Plan did not include the above listed point.

Based on observation and interview, it was determined the facility failed to ensure Exit discharges were arranged to provide a level hard-packed walking surface free of obstructions, affecting one of two exit stairways.

Findings include:

1. Observation on March 14, 2018, at 1:15 p.m., revealed the exterior East side exit stairway walking surface was very muddy; the mulch was washed away by melting snow; metal decorative garden edging was broken away and laying off to the side; and snow was accumulated on the grassy area in the path to the public way.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the condition of the exit discharge.

Based on observation and interview, it was determined the facility failed to ensure vertical openings between floors were enclosed with construction having a fire resistance rating, affecting one of two elevator shafts.

Findings include:

1. Observation on March 14, 2018, at 11:35 a.m., revealed inside elevator #1, there was an unsealed, sprinkler pipe penetration of the shaft wall.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the unsealed penetration of the elevator shaft.

Based on observation and interview, it was determined the facility failed to ensure hazardous areas protected by an automatic fire extinguishing system, were separated from other spaces by smoke resistant partitions, affecting two of four smoke compartments within this component.

Findings include:

1. Observations made on March 14, 2018, between 11:00 a.m. and 11:10 a.m., revealed the following hazardous area deficiencies:

a. 11:00 a.m., inside the mechanical/boiler room, there was an unsealed white wire penetration, above the entrance double doors
b. 11:10 a.m., inside the Receiving storage room, there was an unsealed white wire penetration, located above the desk. The room was greater than 50 square feet in area and contained numerous cardboard and paper storage boxes.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to ensure automatic sprinkler system components were maintained within a smoke tight assembly, affecting two of two levels within the facility.

Findings include:

1. Observations on March 14, 2018, between 9:30 a.m. and 10:10 a.m., revealed there were missing sprinkler escutcheon plates missing at the following locations:

a. 9:30 a.m., inside room 212, by entrance door
b. 10:10 a.m., inside the east side, community rest room

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the missing sprinkler escutcheons.

2. Observation on March 14, 2018, at 11:15 a.m., revealed inside the first floor , Holding room, there was a ceiling tile missing, which could effect activation of the sprinkler system.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the missing ceiling tile.

Based on observation and interview, it was determined the facility failed to ensure fire extinguishers were inspected at required intervals, affecting one of four smoke compartments.

Findings include:

1. Observation made on March 14, 2018, between 10:45 a.m. and 11:00 a.m., revealed monthly inspection tags for the portable fire extinguishers indicated the last visual inspection was completed on October 2, 2017, at the following locations:

a. 10:45 a.m., inside the first floor, electrical room
b. 11:00 a.m., inside the mechanical/boiler room

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed monthly fire extinguisher inspections were past due.

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of power strips and extension cords, affecting one of four smoke compartments.

Findings include:

1. Observation on March 14, 2018, at 10:00 a.m., revealed inside the second floor, electrical room, there were daisy chained surge protectors powering a cable television receiver.

Interview at the exit conference with the Hospital President and the Maintenance Director on March 14, 2018, at 2:30 p.m., confirmed the daisy chained power strips.