Nelson County Health System

“AGREEMENT FOR CRED. AND PRIV FOR TELEMEDICINE CFR(s): Agreements for credentialing and privileging of telemedicine physicians and practitioners. (1) The governing body of the CAH must ensure that, when telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site hospital, the agreement is written and specifies that it is the responsibility of the governing body of the distant-site hospital to meet the following requirements with regard to its physicians or practitioners providing telemedicine services: (i) Determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff. (ii) Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. (iii) Assure that the medical staff has bylaws. (iv) Approve medical staff bylaws and other medical staff rules and regulations. (v) Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. (vi) Ensure the criteria for selection are individual character, competence, training, experience, and judgment. (vii) Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society. (2) When telemedicine services are furnished to the CAH’s patients through an agreement with a distant site hospital, the CAH’s governing body or responsible individual may choose to rely upon the credentialing and privileging decisions made by the governing body of the distant-site hospital regarding individual distant-site physicians or practitioners. The CAH’s governing body or responsible individual must ensure, through its written agreement with the distant-site hospital, that the following provisions are met: (i) The distant-site hospital providing telemedicine services is a Medicare-participating hospital. (ii) The individual distant-site physician or practitioner is privileged at the distant-site hospital providing the telemedicine services, which provides a current list of the distant-site physician’s or practitioner’s privileges; (iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the CAH is located; and (iv) With respect to a distant-site physician or practitioner, who holds current privileges at the CAH whose patients are receiving the telemedicine services, the CAH has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant-site hospital such information for use in the periodic appraisal of the individual distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the CAH’s patients and all complaints the CAH has received about the distant-site physician or practitioner. This Standard is not met as evidenced by: 37620 Based on medical staff and governing bylaws review, medical staff meeting minutes, credentialing document review, and staff interview, the Critical Access Hospital’s (CAH’s) medical staff failed to recommend the appointment /reappointment/privileges for 1 of 1 hospital’s (Hospital #1) physicians reviewed who provided services to the CAH through telemedicine. Failure of the medical staff to recommend appointment/reappointment/privileges of telemedicine medical staff members placed the CAH’s patients at risk of receiving services from unqualified practitioners. Findings include: Review of the “Medical Staff Bylaws of the Nelson County Health System” occurred on 01/22/25. These bylaws, effective 10/25/22, stated, “. . . Article IV Procedures for Appointment and Reappointment . . . Section 2 Appointment Process Subsection 1 . . . the Medical Staff shall review the competed [sic] application and make a recommendation to the governing body that the applicant be either appointed to the Medical Staff or rejected. Section 3 Reappointment Process Subsection 4 . . . the Medical Staff shall review the information for reappointment and make written recommendations to the governing body through the administrator, concerning the reappointment, non-reappointment and/or clinical privileges of each practitioner . . . Article IX Officers and Committees Section 2 Duties of Officers Subsections 1 . . . The Chief-of-Staff: Call and preside at all meetings of the Medical Staff and shall be a member exofficio, of all NCHS [Nelson County Health System] committees. . . Addendum H Article VIII Medical Staff Categories Section 6 Telemedicine Staff . . . Individuals providing telemedicine services from a ‘distance site’ must be appointed to the Telemedicine Staff . . .” Review of the governing body’s “Corporate Bylaws of the Nelson County Health System” occurred on 01/22/25. These bylaws, effective 05/06/03, stated, “. . . Article 6. . . . Section 9(a). Medical Staff. Appointments to the medical staff shall be made by the Board of Directors of the Corporation. . . . The board delegates to the medical staff the authority to recommend and evaluate regarding professional competence, appointments, re-appointments and staff privileges generally. . . .” Review of providers’ 2023-2024 credentialing files occurred on 01/22/25 and indicated the following: - Physician #1 lacked evidence of reappointment by the Chief -of-Staff for August 2024 - Physician # 2 lacked evidence of reappointment by the Chief-of-Staff for initial appointment November 2024. Review of the Medical Staff meeting minutes failed to provide evidence the chief of staff was present at the medical staff meeting on 08/19/24 when Telemedicine Physician #1 was recommended for reappointment/privileges and on 11/18/24 when Telemedicine Physician #2 was recommended for initial appointment. Upon request on 01/22/25 and 01/23/25, the CAH failed to provide evidence of written recommendation from the Chief of Staff for Telemedicine Physician #1’s reappointment and Telemedicine Physician #2’s Initial Appointment. During an interview on 01/23/25 at 11:30 a.m., two administrative staff members (#7 and #8) confirmed the CAH did not have evidence the Chief of Staff of the Medical Staff completed written recommendation to the governing body for approval of reappointment and initial appointment/privileges for Telemedicine Physicians #1 and #2.”

“GOVERNING BODY AND TELEMEDICINE SERVICES CFR(s): §485.616(c)(3) The governing body of the CAH must ensure that when telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the agreement is written and specifies that the distant-site telemedicine entity is a contractor of services to the CAH and as such, in accordance with §485.635(c)(4)(ii), furnishes the contracted services in a manner that enables the CAH to comply with all applicable conditions of participation for the contracted services, including, but not limited to, the requirements in this section with regard to its physicians and practitioners providing telemedicine services. §485.616(c)(4) When telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the CAH’s governing body or responsible individual may choose to rely upon the credentialing and privileging decisions made by the governing body of the distant-site telemedicine entity regarding individual distant-site physicians or practitioners. The CAH’s governing body or responsible individual must ensure, through its written agreement with the distant-site telemedicine entity, that the following provisions are met: (i) The distant-site telemedicine entity’s medical staff credentialing and privileging process and standards at least meet the standards at (c)(1)(i) through (c)(1)(vii). (ii) The individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity providing the telemedicine services, which provides a current list to the CAH of the distant-site physician’s or practitioner’s privileges at the distant-site telemedicine entity. (iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the CAH whose patients are receiving the telemedicine services is located. (iv) With respect to a distant-site physician or practitioner, who holds current privileges at the CAH whose patients are receiving the telemedicine services, the CAH has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant-site telemedicine entity such information for use in periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the CAH’s patients and all complaints the CAH has received about the distant-site physician or practitioner. This Standard is not met as evidenced by: 37620 Based on medical staff and governing bylaws review, medical staff meeting minutes review, credentialing document review, and staff interview, the Critical Access Hospital’s (CAH’s) medical staff failed to recommend the reappointment/privileges for 1 of 1 distant-site entity’s (Telemedicne Entity #3) physicians reviewed who provided emergency care services to the CAH patients through telemedicine. Failure of the medical staff to recommend reappointment/privileges of a telemedicine medical staff member placed the CAH’s patients at risk of receiving services from unqualified practitioners. Findings include: Review of the “Medical Staff Bylaws of the Nelson County Health System” occurred on 01/22/25. These bylaws, effective 10/25/22, stated, “. . . Article IV Procedures for Appointment and Reappointment . . . Section 2 Appointment Process Subsection 1 . . . the Medical Staff shall review the competed [sic] application and make a recommendation to the governing body that the applicant be either appointed to the Medical Staff or rejected. Section 3 Reappointment Process Subsection 4 . . . the Medical Staff shall review the information for reappointment and make written recommendations to the governing body through the administrator, concerning the reappointment, non-reappointment and/or clinical privileges of each practitioner . . . Article IX Officers and Committees Section 2 Duties of Officers Subsections 1 . . . The Chief-of-Staff: Call and preside at all meetings of the Medical Staff and shall be a member exofficio, of all NCHS [Nelson County Health System] committees. . . Addendum H Article VIII Medical Staff Categories Section 6 Telemedicine Staff . . . Individuals providing telemedicine services from a ‘distance site’ must be appointed to the Telemedicine Staff . . .” Review of the governing body’s “Corporate Bylaws of the Nelson County Health System” occurred on 01/22/25. These bylaws, effective 05/06/03, stated, “. . . Article 6. . . . Section 9(a). Medical Staff. Appointments to the medical staff shall be made by the Board of Directors of the Corporation. . . . The board delegates to the medical staff the authority to recommend and evaluate regarding professional competence, appointments, re-appointments and staff privileges generally. . . .” Review of providers’ 2022-2024 credentialing files occurred on 01/22/25 and indicated the following: - Physician #3: lacked evidence of reappointment by the Chief-of-Staff for March 2024. Review of the medical staff meeting minutes failed to provide evidence the chief of staff was present at the medical staff meeting on 03/18/24 when Telemedicine Physician #3 was recommended for reappointment/privileges. Upon request on 01/22/25 and 01/23/25, the CAH failed to provide evidence of a written recommendation from the Chief of Staff for Telemedicine Physician #3’s reappointment. During an interview on 01/23/25 at 11:30 a.m., two staff members (#7 and #8) confirmed the CAH did not have evidence the Chief of Staff of the Medical Staff completed a written recommendation to the governing body for approval of reappointment for Telemedicine Physician #3.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 37620 Based on medical staff and governing bylaws review, credentialing record review, and staff interview, the Critical Access Hospital’s (CAH’s) governing board failed to ensure granting of reappointment followed the bylaws for 2 of 4 providers’ (#4 and #5) files reviewed. Failure to follow the bylaws for reappointment placed the CAH’s patients at risk of receiving services from unqualified providers. Findings include: Review of the governing board’s “Corporate Bylaws of the Nelson County Health System” occurred on 01/22/25. These bylaws, dated 05/06/03, stated, “. . . Article 5. Board of Directors . . . Section 9. Medical Staff. Appointment to the medical staff shall be made by the Board of Directors of the Corporation. . . . The board may re-appoint by written notification all members of the medical staff for a further period of two (2) years provided that such renewal is without written objection by a majority of other members of the medical staff. . . .” Review of the “Medical Staff Bylaws of the Nelson County Health System” occurred on 01/22/25. These bylaws, effective 10/25/22, stated, “. . . Article IV Procedures for Appointment and Reappointment . . . Section 3. Reappointment Process . . . Subsection 4. At least 30 days prior to the final scheduled governing body meeting in the medical staff year, the Medical Staff shall review the information for reappointment and make written recommendations to the governing body through the administrator, concerning the reappointment, non-reappointment and/or clinical privileges of each practitioner . . . Reappointment shall be for two (2) years. . . .” Review of providers’ 2023-2024 credentialing files occurred on 01/22/25 and indicated the following: - Provider #4: the governing body approved reappointment on 08/28/24. Previous appointment was dated 07/21/22 (over 2 years). - Provider #5: the governing body approved reappointment on 08/28/24. Previous appointment was dated 06/04/22 (over 2 years). During an interview on 01/23/24 at 11:45 a.m., two staff members (#7 and #8) confirmed the CAH failed to complete Provider #4 and #5’s reappointments as per medical staff and governing bylaws and confirmed Provider #4 treated patients between 07/21/24 and 08/28/24 and Provider #5 treated patients between 06/04/24 and 08/28/24.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 39687 Based on policy review and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel review the CAH’s health care policies for 1 of 1 year (2023) reviewed. Failure to have the required group of professional personnel review the policies limited the CAH’s ability to ensure the policies were current and followed regulations and standards of practice. Findings include: Review of the policy “Nelson County Health System Policy/Procedure Review” occurred on 01/22/25. This undated policy, stated, “. . . Policy: All department policy and procedure manuals will be completely reviewed on an annual basis and reported to the NCHS [Nelson County Health System] QA [Quality Assurance] committee indicating completion. . . 3. All departments should include departmental staff in the policy/procedure review along with a medical provider (MD) and a [sic] Allied Health Professional (AHP). Signatures are required as noted. . . .” Review of the CAH’s policies occurred on all days of the survey. The policies lacked evidence of review in 2023 by a physician assistant/nurse practitioner/clinical nurse specialist (a required member of a group of professional personnel). Upon request on 01/22/25, the CAH failed to provide evidence a physician assistant/nurse practitioner/clinical nurse specialist reviewed the CAH’s policies. During interview on 01/23/25, at 3:12 p.m., an administrative staff member (#1) confirmed the CAH failed to have a physician assistant/nurse practitioner/clinical nurse specialist review the CAH’s policies. 27221”

“DISCHARGE PLANNING CFR(s): (7) The CAH must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs. This Standard is not met as evidenced by: 27221 Based on review of a facility policy and staff interview, the Critical Access Hospital (CAH) failed to assess it’s discharge planning process on a regular basis for 19 of 22 closed records (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) reviewed. Failure to perform an ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, may result in the development of discharge plans that fail to respond to the patients’ post-discharge needs. Findings include: Review of the policy “Discharge Planning Process” occurred on 01/23/25. This undated policy, stated, “. . . It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the patient’s discharge goals, the preparation of patients to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. . . .” During an interview on 01/24/25 at 9:13 a.m., when asked if the CAH assessed it’s discharge planning process, including for patients readmitted to the facility, to ensure the patients’ post-discharge needs were met, an administrative nurse (#1) stated, “No, [we] don’t reassess the discharge planning process or patients who were readmitted” and added, “We have had a few.””

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 27221 Based on staff interview, the Critical Access Hospital (CAH) failed to develop an organ procurement training program in cooperation with their designated tissue and eye bank. Failure to work in conjunction with the tissue and eye bank limited the facility’s ability to ensure staff members were knowledgeable about donation issues, including how to work with the tissue and eye bank and their duties/roles. Findings include: Upon request on 01/22/25, the facility failed to provide a policy on organ procurement that addressed the training program they developed in cooperation with their designated tissue and eye bank. During an interview on 01/24/25 at 11:50 a.m., an administrative nurse (#1) indicated each staff nurse received training on organ procurement “during orientation and with each death,” but failed to provide documentation of the training provided. During an interview on the morning of 01/24/25, a human resource staff member (#9) also indicated she was unable to locate any documentation of the training provided during orientation.”

“This survey used the 2012 edition of NFPA 101, Life Safety Code, Chapter 19-Existing Health Care Occupancies and the 2012 edition of NFPA 99, Health Care Facilities Code in compliance with 42 CFR 485.623(d)(e). The findings that follow demonstrate noncompliance with these standards. The facility was located in a one-story building of Type II (000) construction with a partial basement. Note: A Fire Safety Evaluation System (FSES) was completed as a result of the 01/22/2025 Life Safety Code survey. The FSES was specifically used as an alternative safety method for K 161 (Building Construction Type). The facility passes the FSES when all other deficiencies have been corrected.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 31888 One-story buildings of Type II (000) construction are required to be protected by an automatic sprinkler system. Without a sprinkler system, Type II (111) construction is required. 19.1.6.2 through 19.1.6.7. The facility failed to provide a construction type that met the requirements of the Life Safety Code. Observation determined the steel I-beams and columns were not protected as a one-hour fire rated assembly. Failure to meet the requirements of building construction type increases the risk of death or injury due to fire. This deficiency affected the entire facility.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 31888 Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1 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. 9.6.1.3. 2010 NFPA 72, 14.1.1 The facility failed to test the fire alarm system as required. Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e). Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 10/10/2024. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year. Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire. This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 31888 Fire extinguishers shall be manually inspected when initially placed in service and thereafter either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 19.3.5.12, 9.7.4.1, NFPA 10 7.2.1.1, 7.2.1.2 The facility failed to inspect and maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Record review and observation determined no documentation was available to indicate inspections of portable fire extinguishers throughout the facility had been completed during October, November, and December 2024. Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire. The deficiency affected all portable fire extinguishers in the facility.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 31888 The facility failed to conduct fire drills as required. Fire drill records review determined: 1) No fire drills were conducted on the Day Shift during the first and second quarters in the past year. 2) No fire drills were conducted on the Night Shift during the first, second, third and fourth quarters in the past year. Failure to conduct fire drills as required increases the risk of death or injury due to fire. The deficiency affected six (6) of twelve (12) drills in the past year.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 31888 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this code. 8.3.3.1. Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2 The facility failed to inspect and test fire rated door assemblies throughout the facility. Review of documentation and interview with staff determined all fire rated door assemblies had not been inspected in the past year. Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire. The deficiency affected numerous fire rated door assemblies throughout the facility.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 31888 The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. (2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating. Diesel-powered EPS installations that do not meet the requirements shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 99 6.4.4.1.1.4, NFPA 110 8.4.2, 8.4.2.3 Review of generator test records and interview with staff: 1) Did not indicate the minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the 125 kW diesel generator loaded the generator to at least 30% (37.5 kW) of the nameplate rating. The facility did not perform annual supplemental load exercises as required when diesel generators are not loaded to 30% of nameplate rating or manufacturer’s recommended temperature during the required monthly exercises. 2) Determined the monthly tests of the emergency generator were not conducted for all months during the past year. Failure to inspect, test and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.”