Dunkirk Rehabilitation & Nursing Center
June 14, 2018 Certification Survey

Standard Health Citations

FF11 483.80(a)(3):ANTIBIOTIC STEWARDSHIP PROGRAM

REGULATION: §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard Survey completed on 6/14/18, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility did not implement an antibiotic stewardship program until (MONTH) 1, (YEAR). The finding is: Review of the facility policy entitled, Antibiotic Stewardship Program, dated 5/2018 revealed the facility would optimize the treatment of [REDACTED]. The Antibiotic Stewardship Program's main goal is to optimize the treatment of [REDACTED]. In order to achieve this goal, the Centers for Disease Control and Prevention (CDC) have published guidelines that outline the seven core elements required for the successful implementation and maintenance of an effective antibiotic stewardship program. The seven core elements include leadership commitment, accountability, drug expertise, action plans, tracking, reporting and education. Record review of the facility's Antibiotic Usage Report revealed the report was initiated (MONTH) (YEAR). There was no record of a tracking report prior to (MONTH) (YEAR). During an interview on 6/13/18 at 10:36 AM, the Director of Nursing (DON) stated, the Antibiotic Stewardship Program included tracking the facility's antibiotic use, and verifying the culture results to ensure the antibiotic was appropriate was initiated 4/1/18. The DON further stated she was unaware of any previous antibiotic usage tracking information prior to 4/1/18. During an interview on 6/14/18 at 9:40 AM, the Administrator stated, the previous DON should have been tracking the antibiotic usage and he was unaware if it was being completed prior to (MONTH) (YEAR). At 2:10 PM the Administrator further verified there was no record for tracking the antibiotic use prior to (MONTH) (YEAR). 415.19(a) (1,3)

Plan of Correction: ApprovedJuly 12, 2018

F881- The facility will comply and establish an Infection Control Program(IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
1. The facility is continuing to use the Antibiotic Stewardship Program implemented (MONTH) 1, (YEAR) TO ENSURE ALL RESIDENTS ARE MONITORED FOR ACCURACY AND PREVENTION OF MISUSE OF ANTIBIOTICS WITH THE APPROVAL OF THE MEDICAL DIRECTOR.
2. The Director of Nursing was re-educated by the Regional Director of Quality Assurance and Performance Improvement regarding F881 and the Antibiotic Stewardship Program. THE DIRECTOR OF NURSING THEN REINSERVICED ALL LICENSED NURSES ON THE POLICY AND PR(NAME)EDURE AND RATIONALE OF THE ANTIBIOTIC STEWARDSHIP PROGRAM.
3.A monthly audit x 3months will be conducted by the Regional Director of Quality Assurance and Performance Improvement AND REVIEWED TO ensure that successful implementation of the seven core elements are carried out AND MAINTAINED regarding the Antibiotic Stewardship Program.
4.Findings from these audits will be reviewed x3 months at the quality assurance meeting.
Responsible Party: Administrator

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

Based on interview and record review during the Standard survey completed on 6/14/18, the facility did not immediately remove an employee from direct care of residents upon receiving a Criminal History Record Check (CHRC) negative determination letter for the employee. This affected one (Employee #6) of six employees reviewed for Criminal History Record Checks. The finding is: Review of the personnel file for Employee #6 (Certified Nurse Aide) revealed Employee #6 was hired on 11/14/17 and started working at this facility on 11/27/17. Further review revealed a Pending Denial letter for this employee from the CHRC Legal Review Unit was dated 12/5/17 and a Final Denial b letter was dated 1/16/18. Review of the facility's automated time detail system revealed Employee #6 worked in this facility for a total of 43.75 hours beyond the Pending Denial' letter, and Employee #6's last date worked in this facility was 12/12/17. Interview with the Administrator (Authorized Person) on 6/13/18 at 3:50 PM revealed he consulted Employee #6's pay records and found Employee #6 did work beyond the Pending Denial letter. Review of the facility policy called, Criminal History Record Checks, revised 5/5/16, revealed upon receipt of a Proposed Denial letter, the facility will meet with the employee and determine whether to terminate the employee, and the facility will not advocate for the individual or determine that they are cleared, this determination must come from the DOH (Department of Health). According to CHRC Regulations, Part 402, upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department. 402.7(a)(2)(i)

Plan of Correction: ApprovedJuly 4, 2018

R808- The facility will comply and immediately remove employees from direct care of residents upon receiving a Criminal History Record Check (CHRC) negative determination letter for the employee.
1. Employee #6 is no longer employed at the facility.
2. 100% audit of all current employees CHRC letters hired as of 4-1-2018 were audited for submission and supervision sheets.
3. The facility policy and procedure on CHRC was reviewed and no revisions at this time was needed. The HR director was provided a educational counseling on the procedure of CHRC by the Regional Director of Quality Assurance and Performance of Improvement.
4.Weekly audits x4 then monthly x 2 will be completed by the Administrator/ designee to ensure CHRC letters and Supervision sheets are completed and received timely. All audits and findings will be reported to the QA committee x 2 months.
Responsible Party: Administrator.

















FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Standard Survey completed on 6/14/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, two (Residents #19 and 30) of two residents observed for infection control practices during blood glucose monitoring had issues when nursing staff did not disinfect the shared blood glucose meter with a germicidal (a substance that destroys germs) cleaning agent between resident use. Additionally, the facility did not review and update their Legionella water management plan and environmental assessment annually. This affected the entire building, including one of one resident unit. The findings are: 1. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Clinical Physician order [REDACTED]. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Review Report revealed a physician's orders [REDACTED]. A continuous observation on 6/14/18 at 10:42 AM revealed Licensed Practical Nurse (LPN) #1 was observed to go into Resident #19's room. LPN #1 placed a glucose meter next to the sink (without placing a barrier underneath), donned (put on) gloves and used a lancet (needle used to puncture skin for blood sample) to pierce the resident's left middle finger, picked up the glucose meter and touched the testing strip to the drop of blood on resident's finger. LPN #1 obtained the reading, removed the testing strip from glucose meter, removed her gloves and threw them away. The LPN washed her hands for 20 seconds and walked down to her medication cart. The LPN placed the glucose meter on top of the medication cart, unlocked the cart, obtained an alcohol pad and wiped the glucose meter with the alcohol pad, and placed the glucose meter back on top of medication cart. The LPN went back to Resident #19's room to give a dose of insulin and left the glucose meter on top of the medication cart. At 10:46 AM, LPN #1 returned to the medication cart, washed her hands using hand sanitizer, gathered the glucose meter, testing strip, and lancet and went into Resident #30's room. The LPN placed the glucose meter on the sink, donned gloves, placed glucose meter on resident's overbed table (without placing barrier underneath), used a lancet to pierce the resident's right ring finger, picked up the glucose meter and touched the testing strip to the drop of blood on resident's finger. The LPN obtained the reading, removed the testing strip from the glucose meter, removed gloves, and threw them away. The LPN washed her hands for 20 seconds and walked down to medication cart, placed glucose meter on top, and used an alcohol pad to wipe down the glucose meter. During an interview on 6/14/18 at 10:50 AM, LPN #1 stated that's how she always cleans the glucose meters. The LPN stated she did not know what the facility policy was, but someone told her a long time ago to do it that way. During an interview on 6/14/18 at 11:02 AM, the Director of Nursing (DON) stated, the nurses usually use an alcohol pad to clean it. When asked if she knew the facility policy or the manufacturer recommendations the DON stated, I have to review the policy and we recently switched suppliers so I have to see which glucometer we are using. The DON retrieved the glucose meter insert and said, it does say we can use Micro-Kill with alcohol but it doesn't say anything about using an alcohol pad. The DON reviewed the facility policy and stated, it says to cleanse/disinfect the glucose meter with 70% alcohol swab before using and after each use. When asked what the staff should be doing to clean the glucose meter, the DON stated, we are going to use the Clorox wipes now so everyone is on the same page and staff will be in serviced today. During an interview on 6/14/18 at 11:10 AM, LPN #2 stated she uses bleach wipes to clean the glucose meter between residents. She wipes it down and lets it air dry. Review of the EvenCare g3 (glucose monitoring system) user guide revealed the glucose meter should be cleaned and disinfected between each patient. 2. To assess the most recent revision, a review of the document called Risk Management Plan for Legionella Control revealed that written on the cover page of the document was see revision dated 1/22/17. During an interview on 6/13/18 at 1:54 PM, the Administrator stated, the plan was created prior to (YEAR), and was reviewed and updated by himself on 1/22/17. Continued interview revealed the document has not been reviewed since 1/22/17, but there have been no changes since then. Review of the form DOH-5222, Environmental Assessment of Water Systems in Healthcare Settings, revealed it was signed and dated on 8/22/16 by the Maintenance Director. During an interview on 6/13/18 at 3:30 PM the Maintenance Director stated he thought the Environmental Assessment was to be completed every other year, then annually after the second year. Per New York Codes, Rules and Regulation, Part 4- Protection Against Legionella, subpart 4-2, Health Care Facilities: Environmental assessments shall be updated annually and under the following conditions: in the event that one or more cases of [DIAGNOSES REDACTED] are, or may be, associated with the facility; upon completion of any construction, modification, or repair activities that may affect the potable water system; or any other conditions specified by the department. The facility shall retain copies of the completed environmental assessment form in accordance with section 4-2.6 of this Subpart. 415.19(a)(1)(b)(2) Subpart 4-2.3(b), 4-2.4(c)

Plan of Correction: ApprovedJuly 12, 2018

F880- The facility will comply and establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
1.Resident #19 and #30 were assessed by the DIRECTOR OF NURSING,RN on 7-2-18 for adverse effects and THE MEDICAL RECORD WAS REVIEWED AND there were no signs and symptoms of infection.
The Risk Management Plan for Legionella Control was reviewed by the Maintenance Director and Administrator on 6-25-2018.

2. All nurses were re-educated on proper glucose monitoring and equipment care FOR ALL DIABETIC RESIDENTS BY THE DIRECTOR OF NURSING based on the manufacturers policy and recommendations.
In addition to new Glucose monitoring policy and procedure dated (MONTH) (YEAR).Compitiencies regarding glucometer cleaning will be completed on all licensed nurses with 100% compliance.
The Regional Director of Quality Assurance and Performance Improvement
re educated the Administrator and Maintenance Director need for annual review of the Risk Management Plan for Legionella Control Manual and update as needed.
3.The DIRECTOR OF NURSING /DESIGNEE WILL PERFORM Audits of proper cleaning of glucometers AND NURSE PROFICIENCY FOR PROPER CLEANING TECHINIQUES.This will be conducted weekly x 4 weeks,then monthly x 2 on licensed nurses until 100% compliant ON ALL THREE SHIFTS WITHIN THE FACILITY. 2 AUDITS WILL BE CONDUCTED ON EACH NURSE, ONE INITIALLY AND A FOLLOW UP WITHIN 30 DAYS BY THE DIRECTOR OF NURSING.
4.Findings from the Glucometer cleaning audits will be reviewed at the monthly Quality Assurance Meeting x3 months. The Risk Management Plan for Legionella Control will be reviewed annually at the Safety committee meeting.
Responsible Party: Director of Nursing

FF11 483.10(g)(17)(18)(i)-(v):MEDICAID/MEDICARE COVERAGE/LIABILITY NOTICE

REGULATION: §483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 6/14/18, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries. Specifically, for two (Resident #16 and 21) of three residents reviewed for beneficiary protection notification, the facility did not provide residents with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) or denial letter at the termination of Medicare Part A benefits. The findings are: Review of the policy entitled Notification of Medicare A Non-Coverage dated 4/1/18 revealed the SNF denial letter will be issued to the beneficiary or authorized representative upon admission or when Part A services are ending, but the resident remains in the SNF for custodial care. 1. Resident #16 was admitted to the facility on [DATE] under Medicare part A services. The Notice of Medicare Non- Coverage (NOMNC), signed on 1/24/18, included that the resident's Part A services were to end on 1/26/18. There was no evidence that the SNF ABN or denial letter was given to the resident or their representative informing them of their potential liability for payment when the resident remained in the facility for custodial care. Review of the SNF Beneficiary Protection Notification Review form revealed Medicare Part A services started 12/31/17 and ended on 1/26/18. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The form included that the SNF ABN, CMS (Centers for Medicare & Medicaid Services)- was provided to the resident. 2. Resident #21 was admitted to the facility on [DATE] under Medicare Part A services. The Notice of Medicare Non- Coverage, signed on 3/20/18, included that the resident's Part A services were to end on 3/22/18. There was no evidence that the SNF ABN or denial letter was given to the resident or their representative informing them of their potential liability for payment when the resident remained in the facility for custodial care. Review of the SNF Beneficiary Protection Notification Review form revealed Medicare Part A services started 1/30/18 and ended on 3/22/18. The facility initiated the discharge from Medicare part A services when benefit days were not exhausted. The form included that the SNF ABN, CMS- was provided to the resident. During an interview on 6/13/18 at approximately 10:30 AM, the per diem Administrative Assistant stated, I don't think they (the residents) were given the ABN forms, maybe I filled the form out wrong, it's my first-time filling that out. (Referring to the SNF Beneficiary Protection Notification Review form). During an interview on 6/13/18 at 10:35 AM, the Human Resource (HR) Director stated she does give the forms but nobody knows if a resident is going long term unless therapy tells us and that I give a cut letter form but I didn't know about the second form. During further interview on 6/13/18 at 11:13 AM, the per diem Administrative Assistant stated I didn't train the new person (HR Director) regarding the ABN because I used it for Part B only and I retired in December. She further stated she used the chart to know which letters to give a resident and she provided a copy of the chart. The per diem Administrative Assistant also stated she got another form from another facility that has instructions for the ABN that started in (YEAR). Review of the undated SNF Notice Chart indicated a resident that no longer required skilled nursing services on Part A (cut), but is remaining in the SNF at custodial level of care should be provided the NOMNC CMS form # and 2 page cut letter. The chart does not include that the SNF ABN is to be given when Part A services are ending. 415.3(g)(2)(i)

Plan of Correction: ApprovedJuly 12, 2018

F582-The facility will provide the appropriate liability and appeal notices Medicare beneficiaries.
1.Resident #16 and #21 were provided SNF ABN AND DENIAL LETTER-PER CMS,WE WILL BE DISCONTINUING THE 5 DENIAL LETTERS AND THE REVISED SNF ABN WILL BE USED AS OF MAY 7, (YEAR). and denial letter dated 7-2-18 informing them of their potential liability for payment when the resident's remained the facility for custodial care.
2. 100% audit of all residents who have had their Medicare Part A benefits terminated will be reviewed to ensure they had received their SNF ABN AND DENIAL LETTER PER CMS WE WILL BE DISCONTINUING THE 5 DENIAL LETTERS AND THE REVISED SNF ABN WILL BE USED AS OF MAY 7, (YEAR). and Denial letter as of 4-1-2018 to present. Any resident or designated representative that may have affected by this deficient practice will be notified of their right to appeal.
3. The facility has reviewed the Policy on SNF ABN AND DENIAL LETTER PER CMS WE WILL BE DISCONTINUING THE 5 DENIAL LETTERS AND THE REVISED SNF ABN WILL BE USED AS OF MAY 7, (YEAR) and denial letters and the process for reviewing letters with residents or residents representatives and has found to be acceptable. The MDS Coordinator, Resident Care Coordinator, Therapy Director, Financial Director and Social Worker will be re-educated on policy and process.
4.The Social Worker will audit weekly all residents SNF ABN AND DENIAL LETTER PER CMS WE WILL BE DISCONTINUING THE 5 DENIAL LETTERS AND THE REVISED SNF ABN WILL BE USED AS OF MAY 7, (YEAR) notice and any Medicare denial letters for 4 weeks, and then monthly for next 3 months, until compliance rate of 100% is achieved. The findings will be reported to QAPI committee for further evaluation and recommendation to sustain compliance.
Responsible Party: Administrator

Standard Life Safety Code Citations

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 6/14/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not develop a communication plan. The finding is: Record review on 6/12/18 and 6/13/18 of the facility's Emergency Preparedness Plan, last updated 1/24/18, revealed a communication plan was not included. Further review revealed Chapter 7 of the facility's Emergency Preparedness Plan was called, Communications, but Chapter 7 contained no pages. Interview with the Administrator on 6/13/18 at 1:15 PM revealed a communication plan was created for the other long-term care facility for which he is also the Administrator, and the plan should have been changed to meet the needs of this facility and included in this facility's Emergency Preparedness Plan. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(c)

Plan of Correction: ApprovedJuly 4, 2018

E029- The facility will comply with the emergency preparedness communication plan.
1. The Communication Plan was added to the Emergency Preparedness Manual under Chapter 7.
2. The Maintenance Director was reeducated by the Administrator on development of necessary corrections to the Emergency Preparedness Manual.
3.The Emergency Preparedness Manual was audited by the Administrator and Maintenance Director for other deficient areas and corrected as needed.
4.The communication plan will be updated as needed and reviewed at least annually at the Safety Committee Meeting.

Responsible Party: Maintenance Director


Responsible Party: Maintenance Director

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Life Safety Code survey completed on 6/14/18, the facility had not implemented a program for the maintenance of patient care related electrical equipment. This affected resident lifts that were used on one of one resident unit. The finding is: Observation of a stand-up lift located in the corridor of the resident unit on 6/13/18 at approximately 9:15 AM revealed it had a purple sticker from an outside contractor that stated an inspection was performed 5/17 and re-inspection was due 5/18. Review of the Owner's Operating and Maintenance Manual for the brand of lift observed on 6/13/18 revealed a list of items to be inspected and adjusted on a monthly basis, which included: caster base, shifter handle, mast, lift arms and linkage, electric [MEDICATION NAME] assembly, and slings. Interview with the Maintenance Director on 6/13/18 at 10:00 AM revealed there is no regular preventative maintenance performed on the facility's lifts by the facility's maintenance department, which consists of only himself, but he is asked to look at the lifts when something goes wrong. Continued interview with the Maintenance Director revealed the outside contractor who inspected the facility's lifts in (YEAR) has not performed the (YEAR) preventative maintenance yet. Interview with the Administrator on 6/13/18 at 3:55 PM revealed the outside contractor had not performed the (YEAR) preventative maintenance yet on the facility's patient care related electrical equipment. Review of the facility document called, Policy and Procedure for Maintenance of Electrical Equipment Including Test and Intervals for Patient Care Electrical Equipment effective 2/22/17 revealed all facility electrical equipment including patient care electrical equipment will be maintained in accordance with manufacturer's instructions and records of test and maintenance will be kept at the facility. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.5.3, 10.5.3.1.2, 10.5.6, 10.5.6.2, 10.5.6.2.1, 10.5.6.2.2, 10.5.6.3

Plan of Correction: ApprovedJuly 4, 2018

The facility will implement a program for the maintenance of patient care as related to electrical equipment affecting resident lifts.
1.The resident stand -up lift in question was inspected on 6- -18 by the maintenance director based on the owners operating manual. A inspection sticker indicating the lift was inspected and dated was placed on the lift by the maintenance director.
2. The Maintenance Director was re-educated by the Administrator on K921 regarding the testing of all electrical equipment in the facility.
3. A monthly log was developed to include all electrical equipment in the facility to be tested monthly and according to the manufacturers requirements.
4.The monthly equipment inspection log and findings will be reviewed at the monthly safety meeting x 3 months.
Responsible Party: Maintenance Director

EP PROGRAM PATIENT POPULATION

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] 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.** *[For LTC facilities at §483.73(a)(3):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 6/14/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Preparedness Plan did not address continuity of operations during an emergency. The finding is: Record review on 6/12/18 and 6/13/18 of the facility's Emergency Preparedness Plan, last updated 1/24/18, revealed delegations of authority and the facility's succession planning during an emergency were not addressed. Interview with the Administrator on 6/13/18 at 1:00 PM revealed the facility's Emergency Preparedness Plan did not address succession planning. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(a)(3)

Plan of Correction: ApprovedJuly 4, 2018

E007- The facility will comply with the Emergency preparedness plan that must be reviewed and updated at least annually and address the continuity of operations during an emergency.
1. The delegation of authority and the facilities' succession planning during an emergency was added to the Emergency Preparedness Manual in Section 13.
2. The Maintenance Director was reeducated by the Administrator on development of necessary corrections to the Emergency Preparedness Manual.
3. The Emergency Preparedness Manual was audited by the Administrator and Maintenance Director for other different areas and corrected as needed.
4.This will be reviewed annually at the Safety Committee Meeting. Updates will be added as needed.
Responsible Party: Maintenance Director.

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 6/14/18, signage stating that oxygen was stored within a room was not present. This affected one of one resident unit and one of one Dining Room. The findings are: 1. Observation on 6/11/18 at 9:25 AM revealed one E-sized oxygen cylinder was stored on a crash cart in the Clean Utility Room. Further observation revealed the door to the room was not equipped with a sign stating that oxygen was stored within. 2. Observation on 6/11/18 at 11:20 AM revealed one E-sized oxygen cylinder was stored on a crash cart in the Dining Room. Further observation revealed the doors to the room were not equipped with signs stating that oxygen was stored within. Interview with the Director of Nursing on 6/13/18 at 3:10 PM revealed crash carts with the oxygen cylinders are always stored in these rooms. Per the 2012 edition of NFPA 99 Health Care Facilities Code, a precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.4 2012 NFPA 99: 11.3.4, 11.3.4.1, 11.3.4.2

Plan of Correction: ApprovedJuly 4, 2018

The facility will ensure that signage stating that oxygen is stored within the room is posted.
1. Signage was posted on the clean utility room door and dining room door as follows: CAUTION OXIDIZING GAS(ES) STORED WITHIN-NO SMOKING.
2. The Maintenance Director was reeducated by the Administrator on K923 regarding proper signage when and where oxygen is stored.
3.An initial audit was completed by the Maintenance Director on 6- -18 of the entire facility to ensure all areas that store oxygen have the appropriate signage posted.
4.Weekly audits will be conducted by the Maintenance Director for 60 days to ensure the signage is posted. Findings will be brought to the monthly safety meeting on an on-going basis to review the findings.
Responsible Party- Maintenance Director

NAMES AND CONTACT INFORMATION

REGULATION: [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 6/14/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the communications plan did not contain the names and contact information for volunteers. The finding is: Record review on 6/12/18 and 6/13/18 of the facility's Emergency Preparedness Plan, last updated 1/24/18, revealed names and contact information for emergency volunteers, or sources of alternate staffing, did not appear. Interview with the Administrator on 6/13/18 at 1:17 PM revealed the names and contact information for emergency volunteers would have been included in Chapter 7 of the facility's Emergency Preparedness Plan, which is a missing chapter. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(c)(1)

Plan of Correction: ApprovedJuly 4, 2018

EO30- The facility will comply with the Emergency Preparedness requirements specifically to contain the names and contact information for volunteers.
1. The communication plan was added with a list of volunteers to the Emergency Preparedness Manual.
2. The Maintenance Director was reeducated by the Administrator on development of necessary corrections to the Emergency Preparedness Manual.
3. The Emergency Preparedness Manual was audited by the Administrator and Maintenance Director for other deficient areas and corrected as needed.
4. The volunteer list will be updated as needed and reviewed annually at the Safety Committee meeting
Responsible Party: Maintenance Director

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 6/14/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not develop policies and procedures regarding the use of volunteers in an emergency, or other emergency staffing strategies. The finding is: Record review on 6/12/18 and 6/13/18 of the facility's Emergency Preparedness Plan, last updated 1/24/18, revealed the use of volunteers in an emergency, or other emergency staffing strategies, were not addressed. Interview with the Administrator on 6/13/18 at 1:13 PM revealed he was not sure why staffing strategies in an emergency were not included in the facility's Emergency Preparedness Plan, and added that during an emergency, the facility would consider using staffing agencies, staff from local hospitals, local neighbors, staff from affiliated long term care facilities, and the local Resource Center, but this was not included in the written Emergency Preparedness Plan. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedJuly 4, 2018

E024- The facility will comply with Emergency Preparedness and developed policy and procedures regarding the use of volunteers in the Emergency Preparedness Manual.
1.A list of potential volunteers, agency staff and employees from affiliated facilities have been added to Section 13 of the facility Emergency Preparedness Manual for emergency staffing strategies.
2. The Maintenance Director was reeducated by the Administrator for other deficient areas and corrected.
3. The emergency Preparedness Manual was audited by the Administrator and Maintenance Director for other deficient areas and corrected as needed.
4. The above list will be reviewed annually at the Safety Committee Meeting for the need to update of staffing strategies, volunteers and agency staff.
Responsible Party: Maintenance Director

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 14, 2018
Corrected date: July 31, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 6/14/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Preparedness Plan did not address the provision of subsistence needs regarding medical and pharmaceutical supplies during an emergency. The finding is: Record review on 6/12/18 and 6/13/18 of the facility's Emergency Preparedness Plan, last updated 1/24/18, revealed the provision of subsistence needs regarding medical and pharmaceutical supplies during an emergency were not addressed. Interview with the Administrator on 6/13/18 at 1:05 PM revealed the facility's sources and procedures for obtaining medical and pharmaceutical supplies during an emergency were not addressed in the Emergency Preparedness Plan. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(b)(1)(ii)

Plan of Correction: ApprovedJuly 9, 2018

E015- The facility will comply with the emergency preparedness requirements to address the provision of subsistence needs including medical and pharmaceutical supplies during an emergency.
1.The following area was addressed and added to Section 13 of the facility Emergency Preparedness Manual regarding Medical and Pharmaceutical Supplies: In section 13 of the Emergency Preparedness Manual was updated to include a means to maintain subsistence needs and pharmaceutical supplies and needs during a emergency at the facility.
2. The Maintenance Director was reeducated by the Administrator of necessary corrections to the Emergency Preparedness Manual.
3.
The Emergency Preparedness Manual was audited by the Administrator and Maintenance Director for deficient areas and corrected as needed.
4. This will be reviewed annually at the Safety Committee Meeting. Updates will be added as necessary.
Responsible Party: Maintenance Director