Chi Health Nebraska Heart

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 13879 Based on documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers serving the Essential Electrical System. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Documentation review on 11-7-23 at 1:38 pm of the emergency generator maintenance log revealed: 1. No program for exercising the main or feeder breakers was established. 2. Documents provide for the inspection of breakers failed to accurately describe the process of inspection. During an interview on 11-7-23 at 1:38 pm, Staff A confirmed that the failed to be conducted and stated that they conducted thermal imagining on the breaker and not what the work order stated. NFPA Standard: NFPA 99, 2012, 6.4.4.1.2.1 Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer’s recommendations. A.6.4.4.1.2.1 Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.”

“42 CFR 482.41 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, “Existing Health Care Occupancies” of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. CHI Health Nebraska Heart is a two story Type II (III) construction type, was built in 2003 is fully sprinkled, smoke detection in corridors and spaces open to corridors. The facility has the capacity of 63 beds with a census of 32 on the day of survey. CHI Health Nebraska Heart was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41 Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Multiple Occupancies - Contiguous Non-Health CFR(s): NFPA 101 Multiple Occupancies - Contiguous Non-Health Care Occupancies Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.4.1, 19.1.3.4.1 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to maintain a 2-hour fire rated separation between the Medical Office Building and the Hospital. This deficient practice would allow smoke, fire and gases to migrate between the Hospital and Medical Office Building. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Observation on 11-7-23 at 9:59 am revealed the west 1 ½ -hour fire rated double doors leading into the Medical Office Building failed to latch. During an interview on 11-7-23 at 9:59 am, Staff A confirmed the door failed to latch within the doorframe.”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2 This Standard is not met as evidenced by: 13879 Based on observations and interview, the facility failed to assure a door in the means of egress opened with one motion. This deficient practice could delay egress in the event of an emergency. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Observations on 11-7-23 at 9:41 am revealed, the door to the Director of Nursing Office provided a doorknob and thumb lock which required two motions to exit the room if the upper locked was engaged. During an interview on 11-7-23 at 9:41 am, Staff A confirmed that the door required two motions to open the door.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 13879 Based on observation and interview the facility failed to assure that a thumb lock was not functional. This deficient practice would delay egress and cause confusion. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Observation on 11-7-23 at 12:12 pm revealed, a thumb lock installed on the sliding lobby doors. During an interview on 11-7-23 at 12:12 pm, Staff A confirmed the thumb lock on lobby doors.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure doors to hazardous areas latched within the doorframe and that ceiling tiles were in place. These deficient practices would allow fire, smoke and gases to migrate into the exit corridor. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Observation on 11-7-23 between 9:35 am and 10:52 am revealed: 1. Patient room 109 was used as a storage room, there was no self-closing device. 2. The door behind Nurses Station at Pod 2 equipped with a self-closing device failed to close and latch within the doorframe. 3. The Server room located within the Shell space door was held open with wooden door chock. 4. The door 1099 Sterile Processing equipped with a self-closing device, failed to close and latch within the doorframe. 5. The east door to the Data Center 1.154 equipped this a self-closing device failed to close and latch within the doorframe. 6. Unsealed penetration around conduits in the ceiling of the Network Closet. 7. Door 1.143 to the Staff Lounge equipped with a self-closing device, failed to close and latch within the doorframe. During an interview on 11-7-23 between 10:32 am and 10:52 am, Staff A confirmed doors failed to close and latch within the frame, doors failed to provide self-closing devices and unsealed penetrations.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure that the kitchen exhaust hoods were free of excessive grease, failed to provide a cleaning schedule, failed to assure the wheeled cooking appliances under the hood provided chain to prevent movement and failed to maintain wheel chocks for appliances under the hood. These deficient practices would increase the potential for a fire, as a fire under the hood could possibly not be extinguished effectively. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Observations on 11-7-23 at 10:42 am revealed, 1. Gas powered, wheeled cooking appliances under the serving hood was not equipped with chains or similar devices to limit strain on fuel gas connections. 2. The wheeled stove/oven under the serving hood, failed to provide a method to ensure appliance would be returned to the original designed location. 3. The serving hood was extremely greasy, the filters appeared dirty. 4. No cleaning schedule was provided. During interview on 11-7-23 at 10:42 am, Staff A confirmed no chain was provided behind the gas appliance and lack of wheel-chocks for the equipment under the hood. Staff B stated the hood was cleaned professionally semi annually and stated no other cleaning schedule was provided. NFPA Standard: 1999 NFPA 54, 5.1.16 Avoiding Strain on Gas Piping. Gas utilization equipment shall be supported and so connected to the piping as not to exert undue strain on the connections. NFPA Standard: 2001 NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure that the appliance is returned to an approved design location.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to assure fire sprinklers were not obstructed and that the ceiling tiles were in the grid and smoke tight. This deficient practice would not allow the sprinkler system to operate as designed which would cause a delay in protection adding smoke, fire and gases to the area. The facility has the capacity of 63 beds with a census of 32 on the day of survey. Findings are: Observation on 11-7-23 at 10:13 am and 10:45 am revealed: 1. The escutcheon in the Biohazard Room within the Lab was not sealed at the ceiling. 2. Open ceiling tile in room 1.153. 3. Sprinkler in the Network Closet appeared to be located too close to the servers. During an interview on 11-7-23 at 10:13 am and 10:45 am, Staff A confirmed unsealed penetration, open ceiling tiles and obstructed sprinkler.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire, smoke and gases within the exit corridors. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Observation on 11-7-23 at 9:24 am and 9:42 am revealed, 1. The north side double doors to the second floor waiting area “fishbowl” had an excessive gap between the doors. 2. The west door to the south side double doors to the second floor waiting area “fishbowl” failed to latch within the doorframe. During the exit interview on 11-7-23 between 9:24 am, Staff A confirmed the door were obstructed or held open and had an excessive gap.”

“Health Care Facilities Code - Other CFR(s): NFPA 101 Health Care Facilities Code - Other List in the REMARKS section any NFPA 99 requirements (excluding Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Health Care Facilities Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to limit the use of holiday lights. This deficient practice could create electrical injury and fire hazard. The facility has a capacity of 63 beds with a census of 32 on the day of survey. Findings are: Observation on 11-7-23, at 10:05 am, revealed, holiday lights attached to the walls in the Anesthesiology Office with no written policy to limit the use to 90 days. During an interview on 11-7-23 at 10:05 am, Staff A confirmed the use of holiday lights without a limiting policy. NFPA Standard: 2011, NFPA 70, article 590.3 Time Constraints. (B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.”

“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: 13879 Based on documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers serving the Essential Electrical System. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Documentation review on 11-7-23 at 1:38 pm of the emergency generator maintenance log revealed: 1. No program for exercising the main or feeder breakers was established. 2. Documents provide for the inspection of breakers failed to accurately describe the process of inspection. During an interview on 11-7-23 at 1:38 pm, Staff A confirmed that the failed to be conducted and stated that they conducted thermal imagining on the breaker and not what the work order stated. NFPA Standard: NFPA 99, 2012, 6.4.4.1.2.1 Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer’s recommendations. A.6.4.4.1.2.1 Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to cover electrical boxes. This deficient practice would create electrical injury and increase a fire hazard. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Observation on 11-7-23 at 11:04 am revealed, an open electrical junction box on the HVAC unit #1. During an interview on 11-7-23, at 11:04 am, Staff A confirmed the open junction box.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring. This deficient practice would create an increased fire hazard. The facility has the capacity for 63 beds with a census of 32 on the day of survey. Findings are: Observation on 11-7-23 at 10:07 am revealed, extension cords were used to power facility servers. During an interview on 11-7-23 at 10:07 am, Staff A confirmed the extension cords.”