Boone County Health Center

“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: 27395 Based on record review and staff interview, the facility failed to inspect the emergency electrical system (EES) main and feeder breakers annually, and failed to exercise these circuit breakers periodically for 2 of 2 emergency generators. This practice increased the potential that emergency power would not be supplied to the facility. Findings are: Record review on 4/18/24 at 11:48 am revealed documentation was not provided to verify emergency electrical system (EES) main and feeder circuit breakers were inspected annually and exercised periodically. In an interview on 4/18/24 at 11:48 am, Maintenance A confirmed the testing was not conducted. NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be maintained and tested in accordance with 6.4.4.1.2. 6.4.4.1.2 Maintenance and Testing of Circuitry. 6.4.4.1.2.1* Circuit Breakers. 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.”

“42 CFR 483.90(a)(b) 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 18, New Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Boone County Health Center is a one story building of Type II (000) construction that was built in 2021 - 2022, and is fully fire sprinkler protected. There is supervised smoke detection located in the corridors. The facility has a capacity of 22 beds. Boone County Health Center was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a)(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“42 CFR 483.90(a)(b) 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. Boone County Health Center is a one story building of Type II (000) construction that was built in 1950 - 2010, and is fully fire sprinkler protected. There is supervised smoke detection located in the corridors. The facility has a capacity of 22 beds. Boone County Health Center was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a)(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: *Required manual fire alarm system; and *Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and *Automatic sprinkler system, if installed; and *Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 27395 Based on observation and staff interview, the facility allowed a self-closing hazard room door to be held open by an unapproved method. This practice would allow smoke to migrate into the Kitchen. Findings are: Observation on 4/18/24, at 1:30 pm revealed the Kitchen Janitor A133 door was propped open by a door chock, which prevented the corridor door from self-closing. In an interview on 4/18/24, at 1:30 pm, Administration A acknowledged the findings, and removed the door chock at the time of observation.”

“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: 27395 Based on record review and staff interview, the facility failed to conduct fire drills under varying times and conditions. This practice did not provide training for staff to respond to a fire emergency during various activities and staffing levels. Findings are: Record review on 4/18/24, at 11:06 am of fire drills revealed fire drill times were not varied by one hour for the 2nd shift in 2023: 2/27/23 at 9:30 pm and 11/27/23 at 10:00 pm. In an interview on 4/18/24, at 11:06 am, Maintenance A acknowledged the findings.”

“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: 27395 Based on record review and staff interview, the facility failed to inspect the emergency electrical system (EES) main and feeder breakers annually, and failed to exercise these circuit breakers periodically for 2 of 2 emergency generators. This practice increased the potential that emergency power would not be supplied to the facility. Findings are: Record review on 4/18/24 at 11:48 am revealed documentation was not provided to verify emergency electrical system (EES) main and feeder circuit breakers were inspected annually and exercised periodically. In an interview on 4/18/24 at 11:48 am, Maintenance A confirmed the testing was not conducted. NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be maintained and tested in accordance with 6.4.4.1.2. 6.4.4.1.2 Maintenance and Testing of Circuitry. 6.4.4.1.2.1* Circuit Breakers. 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.”