HospitalInspections.org

Based on documentation review and interview, the facility failed to develop and maintain a comprehensive emergency preparedness program that was updated at least annually.

Findings include:

On 6/5/2019, document review of the facility's "All Hazards Plan" revealed no evidence that it had been reviewed or updated at least annually.

Note: The Administrator provided a copy of the facility's "Quality and Patient Safety Committee" meeting minutes dated 4/25/2019. The meeting minutes showed the facility's "Emergency Management" plan was on the agenda for review, however, the minutes did not show the facility's review or updates made to the Emergency Preparedness Plan.

Based on document review and interview, the facility failed to develop and maintain a comprehensive emergency preparedness program that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

Findings include:

On 6/5/2019, document review revealed the facility's Emergency Preparedness Plan (EPP) was not based on facility-based and community-based risk assessments. The EPP did not contain a community-based risk assessment. The Administrator confirmed a community-based risk assessment was not completed.

Although the facility completed a facility-based risk assessment, it was not used as a basis for the EPP. The facility provided a corporate-produced EPP that was not facility specific. This was evidenced by the inclusion of emergency response plans for incidents not identified as a "risk" in the facility-based risk assessment and failure to include response plans for incidents identified as "high-risk" in the facility-based assessment. Specifically, the EPP included plans for hurricanes, tornados, and fire response in a building with multiple floors, but failed to include plans for missing residents, temperature extremes, mass casualties, and infectious disease outbreaks that were identified as "high-risk" in the facility-based risk assessment. The Administrator acknowledged the EPP was a corporate document and not facility specific.

Based on document review and interview, the facilty failed to address its resident 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.

Findings include:

On 6/5/2019, a review of the Emergency Plan revealed:

The facility failed to include a documented assessment of the resident population, including persons at-risk.

The facility failed to ensure continuity of operations through delegation of authority for positions identified as essential during the activation of its emergency response plan.

The facility failed to include a written succession plan for critical roles in the event that current staff and leadership are not available. Specifically, the facility's Emergency Preparedness Plan did not identify who was authorized to act in the absence of the administrator or person legally responsible for the operations. The Administrator acknowledged the Quality Assurance Manager as the "alternate" Administrator, but it had not been designated in writing.

Based on document review and interview, the facility failed to provide 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.

Findings include:

On 6/5/2019, a review of the Emergency Plan revealed the facility failed to provide documented evidence that efforts were made to contact local, tribal, regional, State and Federal agencies to collaborate and cooperate in planning efforts for an integrated emergency response.

Based on observation, interview and documentation review, the facility failed to implement the policies and procedures for the subsistence needs for staff and patients.

Findings include:

On 6/5/2019, a review of the facility's Emergency Preparedness Plan revealed the facility failed to establish policy and procedures to provide for sewage and waste disposal. The Maintenance Director confirmed the facility did not have a written policy in place that addresses disposal of sewage and waste in the event of an emergency.

Based on document review and interview, the facility failed to provide policies and procedures for sheltering in place.

Findings include:

On 6/5/2019, documentation review revealed that the facility did not have a written policy and procedure for sheltering in place. The Administrator confirmed a written policy was not included in the facility's Emergency Preparedness Plan.

Based on document review and interview, the facility failed to develop and implement emergency preparedness policies and procedures for a system of medical documentation that preserves resident information, protects confidentiality of resident information, and secures and maintains the availability of records.

Findings include:

On 6/5/2019, documentation review revealed the facility did not have a written policy and procedure in place for medical documentation. The Administrator confirmed a written policy was not included in the facility's Emergency Preparedness Plan.

Based on document review and interview, the facility failed to develop and implement emergency preparedness policies and procedures for the use of volunteers in an emergency or other staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency.

Findings include:

On 6/5/2019, documentation review revealed the facility did not have a written policy and procedure in place for the use of volunteers in an emergency. The Administrator confirmed a written policy was not included in the facility's Emergency Preparedness Plan.

Based on document review and interview, the facility failed to develop and implement emergency preparedness policies and procedures to establish arrangements with other facilities and other providers to receive residents in the event of limitations or cessation of operations to maintain the continuity of services to residents.

Findings include:

On 6/5/2019, documentation review revealed the facility did not have a written policy and procedure in place to maintain the continuity of services to residents in the event of limitations or cessation of operations. The Administrator provided a written transportation agreement with their vendor, however, confirmed the facility did not have written agreements with other facilities or providers to receive residents in the event of an emergency.

Based on documentation review and interview, the facility failed to provide policies and procedures for the facilities role when under a waiver declared by the Health and Human Services Secretary for provision of care and treatment at an alternate care site.

Findings include:

On 6/5/2019, a review of the Emergency Preparedness Plan revealed there was not a policy and procedure in place regarding the role of the facility under a waiver declared by the Health and Human Services Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. The Administrator acknowledged this deficiency.

Based on documentation review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated annually.

Findings include:

On 6/5/2019, documentation review revealed the facility did not have a written communication plan included in its Emergency Preparedness Plan. The Administrator confirmed a written policy was not included in the facility's Emergency Preparedness Plan.

Based on documentation review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that included the names and contact information for: staff, entities providing services under arrangement, patients' physicians, other facilities and volunteers.

Findings include:

On 6/5/2019, review of the Emergency Preparedness Plan revealed the facility did not have a communication plan that included the names and contact information for: staff, entities providing services under arrangement, patients' physicians, other facilities and volunteers.

Based on documentation review and interview, the facility failed to provide contact information for: Federal, State, tribal, regional, or local emergency preparedness staff; the State Licensing and Certification Agency; the Office of the State Long-Term Care Ombudsman; and other sources of assistance.

Findings include:

On 6/5/2019, a review of the Emergency Preparedness Plan revealed the facility did not have contact information for: Federal, State, tribal, regional, or local emergency preparedness staff; the State Licensing and Certification Agency; the Office of the State Long-Term Care Ombudsman; and other sources of assistance.

Based on documentation review and interview, the facility failed to develop a communication plan that provided for a primary and alternate means for communicating with facility staff, Federal, State, tribal, regional, and local emergency agencies.

Findings include:

On 6/5/2019, a review of the Emergency Preparedness Plan revealed the facility did not have a communication plan that provided for an alternate means for communicating with facility staff, Federal, State, tribal, regional, and local emergency management agencies. The Administrator confirmed the facility had not identified, in writing, an alternate means to communicate with entities external to the facility in the event primary communication methods become available.

Based on documentation review and interview, the facility failed to include a method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers; a means, in the event of an evacuation, to release resident information; and a means of providing information about the general condition and location of residents under the facility's care.

Findings include:

On 6/5/2019, documentation review revealed the facility did not have a written policy and procedure in place for sharing information and medical documentation for patients under the facility's care with other health providers, nor did the facility include means to release resident information in the event of an evacuation or means of providing information about the general condition and location of residents under the facility's care. The Administrator confirmed the facility did not include a written policy for the sharing of information in the Emergency Preparedness Plan.

Based on documentation review and interview, the facility failed to include a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee.

Findings include:

On 6/5/2019, a review of the facility's Emergency Preparedness Plan revealed the facility did not include a means of providing information about the facility's occupancy, needs, and ability to provide assistance to the authority having jurisdiction or the Incident Command Center, or designee. The Administrator acknowledged this deficiency.

Based on documentation review and interview, the facility failed to participate in a full-scale exercise that was community-based and failed to conduct a second full-scale exercise that was community-based or a tabletop exercise using a narrated, clinically-relevant scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

Findings include:

On 6/5/2019, an interview with the Administrator confirmed the facility had not conducted a community-based exercise and failed to conduct a second full-scale, community-based exercise or tabletop exercise to date.

On 6/6/2019, the Administrator provided a copy of an "Emergency Management Critique" completed after an actual power outage occurred on 9/22/18. However, there was no documented evidence that demonstrated cooperation or collaboration with local emergency response agencies. An interview with the Administrator confirmed that only personnel from the facility participated in response to the emergency and assistance from outside agencies was not requested nor required.

National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet.
6.2.9.7.1* The list shall include the following:
(1) Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)* Loading
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.


Based on observation and interview, the facility failed to maintain its automatic fire sprinkler system.

Findings include:

On 06/06/19 and 06/07/19, the following fire sprinkler concerns were observed:

1) Numerous locations in all sections of the building had fire sprinkler heads and/or their escutcheons and cover plates were found with signs of leakage, corrosion, physical damage and/or loading. (Loading is defined as being covered with foreign material such as with paint, dirt or lint.)

2) The spare fire sprinkler box did not contain a list of sprinkler heads installed in the facility to include:
a) sprinkler identification number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating.
b) general description.
c) quantity of each type to be contained in the cabinet.
d) issue or revision date of the list.

The Facility Manager was not aware of the requirement for a list of spares, nor was he aware the fire sprinklers had signs of leakage, corrosion, paint, or other foreign materials.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

Article 200.8 - Ground-Fault Circuit-Interrupter Protection for Personnel. Ground-fault circuit-interrupter protection for personnel shall be provided as required in 210.8(A) through (D). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
(B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Out doors
(5) Sinks - where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink
(6) Indoor wet locations
(7) Locker rooms with associated showering facilities
(8) Garages, service bays, and similar areas other than vehicle exhibition halls and showrooms

Article 400 - Flexible Cords and Cables
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
1) As a substitute for the fixed wiring of a structure
2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3) Where run through doorways, windows, or similar openings
4) Where attached to building surfaces
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Article 408.4 - Field Identification Required
A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.


Based on observation and interview, the facility failed to maintain electrical wiring, equipment and installations as required by NFPA 70.

Findings include:

1) On 06/06/19 and 06/07/19, observation of electrical panelboard circuit directories revealed an inadequate degree of detail that prohibited each circuit from being distinguished from all others. The identified panelboards included:
a) KP1
b) KP2
c) X4C
d) P3C
e) L1A
f) P1A
g) L5A
h) P5A
i) P5B
j) XLA
k) XAC
l) P3A
m) P3B
n) L3A

2) On 06/06/19 and 06/07/19, observation of the following areas revealed the unauthorized use of relocatable power taps (RPT) and/or extension cords:
a) Business Office - refrigerator plugged into an extension cord that was plugged into an RPT
b) Administration Office - coffee maker plugged into an RPT
c) CEO Office - one RPT plugged into another RPT powering office equipment
d) CEO Office - refrigerator plugged into an RPT
e) Environmental Service Room - one RPT lugged into another RPT
f) Case Management Office - refrigerator plugged into an RPT that was then plugged into a three-plug multiplier then to receptacle
g) South Nurse Area behind Medication Dispensing Machine (MDM) - the MDM was plugged into an RPT that was plugged into another RPT, then into a wall receptacle.
h) Physical Therapy Office - one RPT was plugged into another RPT then plugged into a wall receptacle. Both RPTs were powering office equipment.
i) Supply Room between 400 and 500 wings - one RPT was plugged into another RPT then plugged into a wall receptacle.

3) On 06/06/19, observation of the physical therapy office revealed exposed electrical wiring under two desks (wiring to electrical receptacles).

4) On 06/06/19, observation of the clean utility room in the 300-hall revealed patient care related electrical equipment impeded access to electrical panels XC2, XC1 and XCA. (Three-foot clearance required in front of electrical panels.)

5) On 06/07/19, observation of the employee lounge revealed two duplex electrical receptacles located above and below a handwashing sink. Neither duplex receptacle could be identified as GFCI protected. A duplex receptacle located in the employee lounge restroom by the handwashing sink was not identifiable as being protected with a GFCI circuit.

The Facility Manager acknowledged each deficiency at the time of discovery. The Administrator acknowledged the deficiencies during the exit interview.

National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition

19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered.
19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected.
19.4.10 All documentation shall be maintained and made available for review by the AHJ.
19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
19.5 Maintenance.
19.5.1 Reports of changes in airflow or noise from the duct system shall be investigated to verify that they are not related to damper operation.
19.5.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer.
19.5.3 If the damper is not operable, repairs shall begin without delay.
19.5.4 Following any repairs, the damper shall be tested for operation in accordance with Section 19.4.


Based on document review and interview, the facility failed to begin repairs of dampers without delay.

Findings include:

On 06/05/19, document review revealed fire and or smoke damper testing was completed 03/26/19. The testing report identified 27 dampers that were not functioning as required and 25 dampers that were not accessible. The facility failed to provide documented evidence that the non-functioning and non-accessible dampers were repaired, being repaired and/or made accessible for any necessary repair.

On 06/05/19, the Facility Manager confirmed that repairs had not been initiated, because the damper testing report was not received by the facility until sometime in May of 2019. The Administrator was not aware that repairs had not been initiated.

Based on document review and interview, the facility failed to conduct fire drills at expected and unexpected times under varying conditions at least quarterly on each shift.

Findings include:

On 06/05/19, document review revealed fire drills for the past twelve months were conducted as follows:

Day Shift 6:00 AM - 6:30 PM
03/25/19 1:58 PM
11/28/18 2:52 PM
08/31/18 7:37 AM
07/19/18 7:35 AM
06/25/18 6:45 AM
06/22/18 1:25 PM
05/08/18 3:00 PM

Night Shift 6:00 PM - 6:30 AM
02/18/19 2:31 AM
12/13/18 3:51 AM

Day shift fire drills from the fourth quarter of 2018 (11/28/18) to the first quarter of 2019 (03/25/19) were spaced four months apart as opposed to three months apart.

Night shift fire drills were not conducted during the second quarter of 2019 and third quarter of 2018.

Document review revealed listed concerns during the 05/08/18, 06/22/18 and 07/19/18 fire drills. No corrective actions were identified for the listed concerns.

On 06/05/19, the Facility Manager acknowledged there was no documentation for the missed night shift drills during the second and third quarters. The Facility Manager was recently hired and was not involved with the fire drills that had noted concerns.

On 06/07/19, the Administrator acknowledged the deficiencies during the exit interview.

Based on observation and interview, the facility failed to prohibit the use of unapproved space heating devices within the building.

Findings include:

On 06/06/19 and 06/07/19, observation of the following areas revealed portable space heaters:
1) Director of Business Office - space heater found under desk (not plugged in).
2) Administrator's Office - space heater found in office (not plugged in).
3) Case Manager's Office - space heater under desk (plugged in).

On 06/07/19, interview with the Facility Manager revealed that he was unaware that portable space heaters were being used in the facility and was unable to produce the specification information for the heating elements of the portable space heaters.

National Fire Protection Association (NFPA) 99, Health Care Facilities Code (2012 Edition)
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). A low-tension value means the ground pin of the attachment plug of the appliance is not making good contact with the grounding blade in the receptacle, thereby defeating the purpose of providing a low-impedance path to ground for the green ground wire of the appliance.


Based on document review, observation and interview, the facility failed to inspect and test electrical receptacles in patient care areas based on intervals defined by documented performance data.

Findings include:

On 06/06/19 and 06/07/19, observation of a multiple electrical receptacles located throughout the building in patient care areas (patient rooms), revealed receptacles and their face plates were cracked and/or broken.

On 06/05/19, document review revealed the facility had failed to inspect and test electrical receptacles as required by National Fire Protection Association (NFPA) 99, Health Facilities Code.

On 06/05/19, the Facility Manager explained he was not aware of the requirement for inspection and testing of electrical receptacles and had not accomplished inspection and testing of the electrical receptacles.

National Fire Protection Association (NFPA) 99, Health Facilities Code, 2012 Edition

11.6.5.4 Cylinders stored in the open shall be protected as follows:
(1) Against extremes of weather and from the ground beneath to prevent rusting
(2) During winter, against accumulations of ice or snow
(3) During summer, screened against continuous exposure to direct rays of the sun in those
localities where extreme temperatures prevail


Based on observation and interview, the facility failed to maintain the Medical Gas Equipment - Cylinder Storage areas by 1) separating combustible materials from oxygen cylinders, and 2) by not segregating empty from full oxygen cylinders.

Findings include:

1) On 06/06/19, observation of oxygen storage areas revealed the following:

a) observation of the outdoor oxygen storage area at the southeast corner of the building revealed accumulated combustible debris (i.e. dried leaves) that was underneath oxygen cylinders.

b) observation of the indoor oxygen storage area located across from the north nurse's station revealed there was combustible material (oxygen tubing and masks in cardboard boxes) within two feet of the oxygen cylinders.

2) On 06/06/19, observation of the oxygen storage area located across from the north nurse's station revealed there were 16 E-sized oxygen cylinders. Four of the cylinders were labeled in-use, six were labeled as full and six were labeled as empty. The six empty cylinders were intermingled with the in-use and full cylinders.

The Facility Manager and Director of Respiratory Therapy acknowledged combustibles were present in both the exterior and interior locations, as well as cylinders were intermingled in the north nurse station oxygen storage room. The Facility Manager was not aware that oxygen cylinders could not rest on the ground.