HospitalInspections.org

K700 Emergency Preparedness Plan and Drills
Findings:
The inspector observed, while accompanied by the Corporate Director of EOC and Facility EOC Director, during the hours of the inspection from 9:30 AM to 3:00 PM on 02/14/19, that there were the following issues:
1) Based on staff interview and review of the records, there were inconsistencies in the after action written reports on community mock disaster drill. The authority having jurisdiction recommends staff review the Federal Register, 81 FR, 63859 to improve future disaster drills.

K914 Electrical systems - Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Corporate Director of EOC and Facility EOC Director, during the hours of the inspection from 9:30 AM to 3:00 PM on 02/14/19, that there were the following issues:
1) Based on observation the facility failed to perform maintenance and testing of receptacles (both hospital-grade and non-hospital-grade types) in patient care areas at intervals based on documented performance data. There were no receptacle testing records available for review for the year 2018 and 2019.

K918 Electrical Systems - Essential Electric System Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Corporate Director of EOC and Facility EOC Director, during the hours of the inspection from 9:30 AM to 3:00 PM on 02/14/19, that there were the following issues:
1) Based on a review of the generator sets monthly load test records, it appeared staff were unfamiliar with NFPA 110 criteria for monthly load tests and how to properly document them for review by the authority having jurisdiction. Additional training is recommended.