Highbridge Woodycrest Center
October 23, 2018 Certification Survey

Standard Health Citations

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2018
Corrected date: December 19, 2018

Citation Details

Based on record review and staff interview, during the recertification survey, the facility did not ensure that the infection prevention and control program included a water management plan that included a facility risk assessment, a water management program that considers ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standards, and water testing protocols to prevent the growth and spread of legionella and other waterborne pathogens. This was evident for the Facility which was reviewed for Infection Prevention, Control & Immunizations. The finding is: During the survey, the State Agency (SA) requested the water management plan developed to prevent Legionella and other waterborne pathogens. The facility did not have a water management plan that included the following requirements: A facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. A water management program that considers the ASHRAE industry standard and the CDC (Centers for Disease Control) toolkit. Specified testing protocols and acceptable ranges for control measures, and documentation of the results of testing and corrective actions taken when control limits are not maintained. On 10/17/18 at 2:00 PM, the Director of Administration (DOA) who oversees maintenance, housekeeping, and all contracts was interviewed. The DOA stated that the facility was taken over by new owners over a year ago. She further stated that the company that tests the water was going to come in to review the contract and what testing was done for the facility. On 10/18/18 at 11:00 AM and 10/22/18 at 11:15 AM, the DOA was re-interviewed. She stated that she was unaware that a facility risk assessment needed to be completed, but she is working on it. She further stated that she signed a contract last night with a company that will do water sampling. The DOA stated the previous owners were contacted and she was informed that no water testing was ever done at the facility. On 10/23/18 at 11:30 AM, the Lead Maintenance/Mechanic (LMM) was interviewed. He stated that the facility conducted monthly chlorine tests of the water. Last year, in (MONTH) (YEAR), the city came to the facility to confirm if the facility had a cooling tower that required Legionnaire's testing, but the facility does not have a cooling tower, so no testing was done. The LMM stated that now, the facility will begin testing for Legionnaire's quarterly, and ten water samples were taken on 10/17/18. He further stated that if any results were positive for Legionella, the contracted company would have to make recommendations regarding what actions should be taken. He stated the contracted company will provide the information to the DOA. 415.19(a)(1-3)

Plan of Correction: ApprovedNovember 16, 2018

F880
In order to correct he deficient practice, the facility will:
1. Revise its Infection Prevention and Control Program (IPCP) to include a water management plan that includes the following requirement:
a. A facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system.
b. A water management program that considers ASHRAE industry standard and the CDC tool kit.
c. Specified testing portals and acceptable ranges for control measures and documentations of results of testing and corrective actions taken when control limits are not maintained.
The facility will conduct a quarterly water testing for one year and then annually and as needed thereafter.
2. The deficient practice has the potential to affect all residents.
3. The lead maintenance engineer will be educated on the requirement of Legionella water sampling. Legionella water sampling will be added to the maintenance schedule and conducted by the lead maintenance engineer quarterly for one year (November (YEAR), (MONTH) 2019, (MONTH) 2019, (MONTH) 2019 and then annually thereafter (November 2020, (MONTH) 2021 etc).
4. The Administrator will audit compliance with the water testing quarterly for one year and then annually. The results of the audit will be submitted to the Quality assurance committee.
5. The date of correction of the deficient practice will be corrected by (MONTH) 17, (YEAR). The person responsible for correcting the deficient practice is the lead maintenance engineer.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Receptacles Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking. 6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2018
Corrected date: December 17, 2018

Citation Details

Based on observations and staff interview, it was determined that the facility did not ensure that a distinctive colored receptacle was provided for emergency outlets. This was observed on all floors. The Finding is: On (MONTH) 18, (YEAR), between the hours of 9:30 a.m., and 2:00 p.m., during the Annual Recertification Survey of the facility it was observed that a distinctive colored receptacle(s) for emergency outlets were not observed on all floors. In an interview with the Director of Maintenance on 10/18/18 at approximately 10:45 a.m., he stated that all outlets are on the generator but if needed colored receptacles will be provided on each floor. (10 NYCRR: 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99:6.5.2.2.4.2)

Plan of Correction: ApprovedNovember 14, 2018

K917
In order to correct this deficient practice the facility will:
1. The facility will install colored receptacles on each floor.
2. The deficient practice has the potential to affect all residents.
3. A monthly inspection and testing on all colored receptacles will be conducted by the facility lead maintenance engineer or his/her designee to ensure that the electrical outlets are in working order.
4. A log of the monthly colored receptacle inspection will be maintained by the lead maintenance engineer.
5. The deficient practice will be corrected (MONTH) 1, (YEAR). The person responsible for correcting the deficient practice is the lead maintenance engineer.

K307 NFPA 101:FEATURES OF FIRE PROTECTION - OTHER

REGULATION: Features of Fire Protection - Other List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire Protection 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 15 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 23, 2018
Corrected date: December 17, 2018

Citation Details

Based on observations and staff interview, it was determined that the facility did not ensure that the gas meter room was free of storage. Reference is made to various combustible storage items. The Finding is: On (MONTH) 18, (YEAR), between the hours of 9:30 a.m., and 2:00 p.m., during the Annual Recertification Survey of the facility it was observed that the Gas meter room located on the main floor adjacent to the parking lot was observed with snow removers, shovels and other combustible materials. In an interview with the Director of Maintenance on 10/18/18 at approximately 11:30 a.m., he stated that all storage will be removed. Chapter 15 NFPA 99

Plan of Correction: ApprovedNovember 14, 2018

K932
In order to correct this deficient practice, the facility will:
1. Remove all items stored in the gas meter room.
2. The deficient practice has the potential to affect all residents.
3. The lead maintenance engineer will conduct a monthly inspection of the Gas Meter Room to ensure that there are no items stored in the Gas Meter room. A signage will be placed outside the door of the gas meter room stating that ?No items can be stored in the gas metered room?.
4. A log of the monthly inspection will be maintained by the lead maintenance engineer.
5. The date of correction for this deficient practice is 12/1/2018 The lead maintenance engineer is responsible for the correction of this deficient practice.

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: Pattern
Severity: Potential to cause minimal harm
Citation date: October 23, 2018
Corrected date: December 17, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed its subsistence needs. Reference is made to the lack of documentation for sewage disposal. The finding is: On (MONTH) 17, (YEAR), between the hours of 9:30 a.m., and 2:00 p.m., during the Annual Recertification Survey of the facility it, the EP plan was thoroughly reviewed and the following component was not included: (C) Sewage and waste disposal. There was no documentation provided to address the missing components. In an interview with the Administrator and staff, on (MONTH) 18 (YEAR), at approximately 02:00 p.m., they stated that it will be provided as part of the Emergency Plan.

Plan of Correction: ApprovedNovember 14, 2018

EO15
In order to correct the deficient practice, the facility will:
1. * Revise its Emergency Preparedness Manual and its Policy and Procedure on Emergency Preparedness to include the provision of subsistence needs specifically on sewage and waste disposal.
* Conduct a facility wide in service on the revised policy and procedure and the revised emergency preparedness policy and procedure manual to educate the staff on the changes.
2. The deficient practice has the potential to affect all residents.
3. The facility will review its policy and procedures on Emergency Preparedness and Sewer Disposal annually. This review shall be conducted by a committee who will make recommendations on revision of the policy if needed in order to meet the facility?s needs and requirements. The committee shall bring their review findings or recommendations to the Facility Administrator.
4. The Facility Administrator will review the committee?s recommendations and make the necessary changes to the policy and procedure as needed. Issues arising from the Policy and Procedure review will be presented to the QA committee.
5. The date of correction for this deficiency is (MONTH) 17, (YEAR). The administrator is the responsible party.