Crest Manor Living and Rehabilitation Center
December 1, 2017 Certification Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: January 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for six (Residents #1, #4, #5, #6, #26, and #42) of six residents reviewed for Accuracy of the Minimum Data Set (MDS) Assessment, the facility did not accurately code the MDS Assessment to reflect the resident's status. The issue involved inaccurate coding for physical restraints. This is evidenced by, but not limited to, the following: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/16/17, revealed that the resident had moderately impaired cognition and bed rail (siderail) was used daily as a physical restraint. The Bed Rail Assessment Tool, dated 8/11/17, revealed the resident used the right siderail to transfer in and out of bed independently. The Comprehensive Care Plan (CCP), dated 9/25/17, and the Nursing Master Care Plan, dated 11/26/17, revealed that the resident used the right siderail in bed for transfers and Activities of Daily Living (ADLs). Interviews conducted on 12/1/17 included the following: a. At 11:01 a.m., Certified Nursing Assistant (CNA) #1 said the resident had a siderail on the right side, and the resident used it to move around and to get out of bed independently. b. At 11:29 a.m., the Registered Nurse Manager (RNM) said that the resident had one siderail on the right side of her bed that she used consistently for independent transfers and bed mobility. She said that the siderail does not restrict the resident from getting in and out of bed. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/28/17, revealed the resident had moderately impaired cognition and the daily use of bed rails as a physical restraint. The CCP, dated 9/10/17, revealed that the resident uses the right siderail in bed for mobility. A Nursing Master Care Plan, dated 11/26/17, revealed that the resident used the right siderail for ADLs and transfers. During an observation and interview on 11/28/17 at 10:56 a.m., the resident was in his room, sitting in a chair next to his bed. The siderail on the bed was in the down position. When interviewed at that time, the resident said he uses the siderail to turn and position himself in bed. Interviews conducted on 12/1/17 included the following: a. At 10:52 a.m., CNA #1 said that the resident was not able to get out of bed on his own. b. At 10:58 a.m., Licensed Practical Nurse (LPN) #1 said the resident used siderails for bed mobility. She said that the resident can occasionally get out of bed, and he uses the siderails to swing his legs over the end of the bed to get up. LPN #1 said the siderail was not a restraint. 3. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/31/17, revealed that the resident had moderately impaired cognition and the daily use of bed rails as a physical restraint. The CCP for Physical Restraints, dated 11/14/17, directed the use of siderails to assist with bed mobility per Therapy recommendation. The Nursing Master Care Plan, dated 11/26/17, directs bilateral siderails for ADLs and transfers. Interviews conducted on 12/1/17 included the following: a. At 10:52 a.m., CNA #1 said that the resident was not able to get out of bed on his own. b. At 10:58 a.m., LPN #1 said that the resident can have siderails per Therapy recommendation but CNAs have told her he is no longer using them to turn himself in bed. LPN #1 said the resident cannot get out of bed on his own. c. At 11:14 a.m., the RNM said the resident cannot get out of bed by himself but does use the siderails to pull himself up a bit when in bed. d. At 11:43 a.m., LPN #2 said she completes the MDS Assessments. She said she was directed to code physical restraint for any resident having siderails. At that time, the Assistant Director of Nursing said one-quarter length siderails were in use. She said if a resident can get out of bed, with siderails raised, the siderails are not a restraint. e. At 1:22 p.m., the Director of Nursing said she was taught to always code siderails as a restraint. She said that siderails are coded as restraints because the MDS definition is to code for intent or use. Center for Medicare and Medicaid Services Resident Assessment Instrument 3.0 Manual Version 1015, (MONTH) (YEAR): P-1 Physical Restraints: any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. P-3 Steps for Assessment 3. Considering the physical restraint definition as well as the clarifications listed below, observe the resident to determine the effect the restrain has on the resident's normal function. Do not focus on the type, intent, or reason behind its use. 4. Evaluate whether the resident can easily and voluntarily remove any manual method or physical or mechanical device, material, or equipment attached or adjacent to his or her body. If the resident cannot easily and voluntarily do this, continue with the assessment to determine whether or not the manual method or physical or mechanical device, material or equipment restrict freedom of movement or restrict the resident's access to his or her own body. P-3: Freedom of Movement means any change in place or position for the body or any part of the body that the person is physically able to control or access. (10 NYCRR 415.11(b))

Plan of Correction: ApprovedJanuary 1, 2018

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
A review of the MDS was completed for Residents #1, #4, #5, #6, #26, and #42 for physical restraints regarding side rails. An review of these resident's was completed to determine the use of the side rails to develop an accurate assessment.
Part 2:
The Director of Nursing, Assistant Director of Nursing, and MDS Nurse are to determine which current residents utilize side rails and review the MDS to ensure proper coding.
Part 3:
The Director of Nursing and MDS nurse will be responsible for reviewing assessments for accuracy before signing off on them. The Staff Education Coordinator will complete a read-and-sign in-service reviewing the accuracy of assessments with those who are responsible for developing the MDS.

Part 4:
The Director of Nursing and MDS Nurse will be responsible for ongoing compliance Audits of MDS of resident?s who utilize side rails will be done monthly for 3 months, and quarterly thereafter, to ensure proper coding. Results will be discussed at the monthly, then quarterly QAPI meetings for review and action as necessary.
Part 5:
Corrective Action will be completed by (MONTH) 30th, (YEAR).

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: January 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for accidents, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, Resident #52 was transported in a wheelchair that was not fitted with devices to support the legs and feet. This is evidenced by the following: Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 10/17/17, revealed that the resident's cognition is severely impaired and that the resident requires total dependence of one for locomotion on the unit. The Comprehensive Care Plan (CCP), dated 10/30/17, included that wheelchair foot pedals are to be used while transporting the resident in a wheelchair. During an observation on 11/28/17 at 12:27 p.m., Certified Nursing Assistant (CNA) #1 transported the resident in her wheelchair from the nurses' station to the unit dining room, a distance of approximately 26 feet. There were no leg rests or foot pedals on the wheelchair and the resident's feet were heard scuffing against the floor. CNA #1 did not ask the resident to lift her feet. During an observation on 11/30/17 at 10:56 a.m., CNA #2 transported the resident in her wheelchair from the nurses' station to her room, a distance of approximately 19 feet. At 11:00 a.m. that day, the resident was transported in her wheelchair from her room to the nurses' station. In both instances, there were no leg rests or foot pedals on the wheelchair. The resident was wearing shoes and her feet could be heard scuffing across the floor. Interviews conducted on 12/1/17 included the following: a. At 10:35 a.m., CNA #1 stated that foot pedals should always be used when a resident is being transported in a wheelchair. She said that the resident may plant her feet when she is being pushed in the wheelchair causing her to fall out and become injured. b. At 11:12 a.m., the Nurse Manager said that she expects leg rests are in place when a resident is being pushed in the wheelchair to prevent injuries. c. At 12:56 p.m., the Staff Educator said that staff receive training on the proper transport of residents in wheelchairs upon hire and annually. She said there were recent in-services on Safe Patient Handling held in (MONTH) and (MONTH) (YEAR). She said that she would expect that foot pedals are always in place when a resident is being pushed in a wheelchair to prevent a potential injury. (10 NYCRR 415.12(h)(2))

Plan of Correction: ApprovedDecember 29, 2017

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
A review of Resident #52?s wheelchair was completed to ensure that it was properly fitted with devices to support the legs and feet. The CNAs who were transporting the resident were counseled.
Part 2:
An audit of all wheelchairs in the facility is to be completed by the Nurse Managers and Therapy Director to ensure that they are fitted with devices to support the legs and feet. If one of the wheelchairs is used by a resident who self ambulates in their chair, then the wheelchair will be fitted with a bag on the back of the chair which will carry the leg/foot rests for that specific chair. Those leg/foot rests will be placed on the chair if and when the resident needs to be transported by staff.
Part 3:
The facility will develop a policy regarding transporting residents in wheelchairs and the use of leg/foot rests. All staff will be educated on the policy by the Staff Education Coordinator.
Part 4:
The Therapy Department and Therapy Aides will be responsible for ongoing compliance under the direction of the Director of Nursing and Assistant Director of Nursing regarding the compliance of wheelchairs with leg/foot rests. Random audits of wheelchairs will be completed monthly for 3 months and quarterly thereafter to ensure compliance.
In addition, the Staff Education Coordinator will be responsible for ongoing compliance under the direction of the Director of Nursing and Assistant Director of Nursing regarding proper transportation of residents. Monthly for 3 months and quarterly thereafter, the Education Coordinator will ensure that the staff is properly transporting residents. Results will be discussed at the monthly, then quarterly QAPI meetings for review and action as necessary.
Part 5:
Corrective Action will be completed by (MONTH) 30th, (YEAR).

FF11 483.45(f)(1):FREE OF MEDICATION ERROR RTS 5 PRCNT OR MORE

REGULATION: §483.45(f) Medication Errors. The facility must ensure that its- §483.45(f)(1) Medication error rates are not 5 percent or greater;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: January 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure that it was free of medication error rates of 5 percent or greater for two of six residents reviewed for medication administration resulting in a 15.38 percent error rate. The issues involved pouring the wrong dose of medication, administering medication at the wrong time, and omitting a medication for Resident #28, and administering the wrong dose of medication for Resident #54. This is evidenced by the following: 1. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/20/17, revealed that the resident had moderately impaired cognition and rated his pain as an 8 on a scale of 1 to 10 on an occasional basis. The physician's orders [REDACTED]. The physician's orders [REDACTED]. During an observation of medication administration on 11/30/17 at 8:52 a.m., the Licensed Practical Nurse (LPN) poured two half tablets of [MEDICATION NAME] 5 mg. The LPN stated she was ready to crush the medications and dispense the medications to the resident when she was stopped by the surveyor. The LPN was questioned regarding the medications in the medication cup, and she said she counted the number of tablets and they were correct. The surveyor pointed out to the LPN that she had poured two half tablets of [MEDICATION NAME] and that the Medication Administration Record [REDACTED]. The surveyor questioned the LPN about the [MEDICATION NAME] 15 mg, she said she missed that one and she should have poured it instead of two [MEDICATION NAME]. Upon entering the room on 11/30/17 at 9:10 a.m., the resident had finished her breakfast and the tray had already been removed from the room. At that time, the resident said she had already finished her breakfast. The LPN proceeded to give the resident the one half tablet of [MEDICATION NAME] with the other medications. Interviews conducted on 11/30/17 included the following: a. At 10:05 a.m., the LPN said she usually counts the number of tablets she has poured to be sure she has them all. She said she accidently poured two half tablets of [MEDICATION NAME], she did not realize she did not pour the [MEDICATION NAME]. She said that breakfast was served from 8:00 a.m. to 8:30 a.m. and that if a medication is ordered to be given before a meal, then it should be given before the resident starts to eat, not after she is finished eating. The LPN said she was not aware of what the medications were used for so she did not know why it is important to give the [MEDICATION NAME] before the meal. b. At 10:16 a.m., the Registered Nurse Manager (RNM) stated that if a medication is ordered to be given before a meal, she expects it to be given before the meal. She said that the preferred way to administer medications was to remove all the medication blister packs from the medication cart and check them for the right medication, right resident, right dosage, right route, and right time. She said omitting a medication, giving the wrong dose, and giving a medication at the wrong time are all medication errors. The RNM said she will initiate a medication error report. 2. Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/3/17, revealed that the resident had severely impaired cognition. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. During an observation of medication administration on 12/1/17 at 9:00 a.m., the LPN poured and administered [MEDICATION NAME] 20 mg to the resident. During reconciliation of the medication administration, the physician's orders [REDACTED]. Interviews conducted on 12/1/17 included the following: a. At 10:34 a.m., the LPN stated that she was not aware that the [MEDICATION NAME] order had been changed. The LPN said she administered it according to the MAR. When looking at the orders at that time, she said it looks like two nurses took off the order but did not transcribe the order on the MAR. b. At 10:43 a.m., the RN Supervisor said she took off the order for [MEDICATION NAME] and transcribed the order on the (MONTH) MAR, but not the (MONTH) MAR. She said that is a medication error because the nurse did not give the correct dose. The facility policy Administration of Oral Medication, dated 11/5/13, included that the standard is that the right medication will be given to the right resident in the right dose and at the right time via the right route followed by the right documentation. (10 NYCRR 415.12(m)(1))

Plan of Correction: ApprovedDecember 29, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.

Part 1:
A review of Resident #28?s MARs and chart were completed to ensure that there were no further medication errors. The resident was also checked to ensure that there were no ill effects from the dosage of [MEDICATION NAME] being given at the wrong time. The RN Nurse Manger initiated a Medication Error Report, which was completed, and the LPN was counseled regarding the medication error, and re-educated on the policies/procedures regarding medication pass.
A review of Resident #54?s MARs and medical chart were completed to ensure that there were not further medication errors/errors of omission and that all orders were transcribed properly on the MARs. The resident was checked for any ill effects due to the wrong dosage being given, and the physician was alerted. Nurses responsible for the transcription error and errors of omission were counseled and re-educated on the policies/procedures.
Part 2:
A review of resident medical orders and MARs will be checked to ensure that there are no further errors of omission. The Staff Educator will monitor Medication Passes and watch for any medication pass errors that could be significant to ensure that the error rate remains under 5%.
Part 3:
All Medication Administration policies will be updated, and a new policy will be created to include issues regarding errors of omission. Nursing staff will be educated on this policy by the Staff Educator. Any nurses who are responsible for medication errors will be re-educated by the Staff Educator on this policy when errors occur.
Part 4:
The Director of Nursing and Staff Educator will be responsible for ongoing compliance. Under direction of the Director of Nursing, the Staff Educator will conduct random audits of the medication passes once a week for three months, reporting results monthly at the monthly QAPI meeting. After three months, the audits will be conducted monthly and reported quarterly if there is a reduction of the medication error rate.
The Director of Nursing will continue to monitor Medication Errors per policies and report monthly and quarterly the results at the QAPI meetings.
Part 5:
Corrective Action will be completed by (MONTH) 30th, (YEAR).

4FGA 400.10 (d):HEALTH PROVIDER NETWORK ACCESS AND REPORTING

REGULATION: The operator of a facility shall obtain from the department ' s health provider network (HPN), HPN accounts for each facility he or she operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, 24-hour, seven-day-a-week contacts for emergency communication and alerts must be designated by each facility in the HPN communications directory. A policy defining the facility's HPN coverage consistent with the facility ' s hours of operation, shall be created and reviewed by the facility no less than annually. Maintenance of each facility ' s HPN accounts shall consist of, at a minimum, the following: (d) current and complete updates of the communications directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 1, 2017
Corrected date: January 30, 2018

Citation Details

Based on interview and record review conducted during the emergency preparedness plan review in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the emergency contact information in the New York State Health Commerce System (NYSHCS) database contained unassigned roles and was not updated monthly. This is evidenced by the following: On 12/4/17 at 10:17 a.m., the Director of Nursing (DON) stated that she was the NYSHCS Administrator for the facility, but when asked to check the emergency contact rolls on the NYSHCS the DON was not sure how to find the information. The DON looked up the contact information for the facility, and there was no contact assigned for the Medical Supplies Receiving Office. The DON stated that she is not sure who that person would be and would have to ask the Administrator. The DON stated that she only updates the NYSHCS as needed, but does not do it monthly or annually. The operator of a facility shall obtain from the Department's Health Provider Network (HPN), HPN accounts for each facility he or she operates and ensure that sufficient, knowledgeable staff will be available and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven day a week contacts for emergency communication and alerts must be designated by each facility in the HPN Communications Directory. Current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis. (10 NYCRR: 400.10, 400.10(d))

Plan of Correction: ApprovedDecember 29, 2017

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
Emergency contact information for the Medical Supplies Receiving Office was updated in the Health Commerce System per guidelines.
Part 2:
A review of all other emergency contacts in the NYSHCS was completed and updated.
Part 3:
The emergency contact information will be reviewed monthly to ensure all information is accurately entered and if any changes need to be made. Once verified, the list will be printed and stored to ensure compliance.
Part 4:
The Director of Nursing (HCS Coordinator) will be responsible for ongoing compliance under the direction of the Administrator.
Part 5:
Corrective Action will be completed by (MONTH) 30th, (YEAR).

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 minimal harm
Citation date: December 1, 2017
Corrected date: January 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one facility potable water system and one of one infection prevention and control program, the facility did not prepare, maintain and properly update infection control policies and procedures. Specifically, the facility did not complete the Legionella Risk Assessment and Policies, legionella prevention procedures were not consistent with facility equipment and infection and control policies and procedures were not reviewed annually. This is evidenced by the following: 1. A review of the facility's Risk Assessment for Legionella, dated 8/30/16, revealed that the Maintenance Director and former Administrator's names were listed as having completed the form. Several pertinent sections were not completed including, but not limited to, is there a recirculation system for the hot water, if you use storage tanks for heated water how and when are the tanks serviced, what is the lowest documented hot water temperature measured at any point within the facility, are mixing valves used at a point after the water heater so that you can maintain higher heating/storage temperatures but deliver at a safe temperature, and are the potable hot and cold water free chlorine levels measured. A review of the facility's policy, Prevention and Control of Legionelosis, dated 2/1/17, the section labeled Operation and Maintenance documented the following: a. Potable water will be stored at less than 68 degrees Fahrenheit (*F). b. Hot water will be stored at less than 140*F and circulated with a minimum return temperature of 124*F. c. Hot water storage tanks will be drained, cleaned and disinfected at least annually. Further review of facility documentation revealed that the facility obtained a Chlorine [MEDICATION NAME] disinfections system in Mid-May (YEAR). There were no policies or procedures to address the Chlorine [MEDICATION NAME] system. When interviewed on 12/1/17 at 8:46 a.m., the Maintenance Director stated that he was not sure why the Department of Health Risk Assessment form was not fully completed. He said he just walked the vendor around the building and they filled it out. The Maintenance Director also stated that the water system did not have a mixing valve, there was a recirculation system for the hot water, they do not perform any service or cleaning on the hot water storage tank, and the chemical that they inject into the tank pretty much kills everything. The hot water storage tank holds water at 109*F to 110*F. 2. A review of the Infection Prevention and Control Program (IPCP) revealed that the Infection Prevention Manual, which included policies and procedures related to the facility's IPCP, was last reviewed in (MONTH) 2008. When interviewed on 12/1/17 at 9:31 a.m., the Director of Nursing stated that the infection control nurse reviews the policies and procedures and recently said that they are due to be reviewed and updated but she had not done that yet. (10 NYCRR 415.19)

Plan of Correction: ApprovedJanuary 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
The facility?s Risk Assessment for Legionella was fully updated and completed, and a policy regarding the Chlorine [MEDICATION NAME] system will be obtained. The Infection Prevention and Control Program is to be reviewed and updated.
Part 2:
The Director of Operations and Director of Maintenance will review any pertinent risk assessments regarding Legionella and the systems to ensure accuracy and completeness of forms.
The Director of Nursing will review IPCP to ensure that the polices have been updated.
Part 3:
The Director of Operations/Director of Maintenance will contact the vendor of the Chlorine [MEDICATION NAME] System and work to create a policy regarding the system. They will also work to update the Legionella policy to ensure accuracy regarding the systems, which are at the facility. The legionella management plan will be reviewed/revised annually. Both will be responsible in training the staff responsible for maintenance of the systems with the new policies.
The Director of Nursing will contact the Infection Control Nurse contracted by the facility and conduct a review of the IPCP along with the Staff Education Coordinator. Any policies that need to be updated will be. The IPCP will be reviewed/revised annually. The Staff Education Coordinator will be responsible in training the staff on new policies/procedures.
Part 4:
The Director of Operations, Director of Maintenance, and Director of Nursing will be responsible for ongoing compliance under the direction of the Administrator. Any new policies will be presented at the monthly QAPI meetings and reviewed by the Medical Director as needed.
Part 5:
Corrective Action will be completed by (MONTH) 30th, (YEAR).

FF11 483.12(a)(3)(4):NOT EMPLOY/ENGAGE STAFF W/ ADVERSE ACTIONS

REGULATION: §483.12(a) The facility must- §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: January 30, 2018

Citation Details

Based on an interview and record reviews conducted during the Recertification Survey, it was determined that for one of eight employee files reviewed, the facility did not screen an employee for prior findings of abuse. Specifically, the facility did not conduct a Nurse Aide Registry Check. This is evidenced by the following: A review of facility records on 12/1/17 revealed that Cook/Tray Aide #1 was hired on 11/7/17. The Nurse Aide Registry Check was dated 12/1/17. In an interview at that time, the Director of Nursing stated that she had to run the employee through the Nurse Aide Registry that day because they could not find one for the employee. A review of the facility policy Resident Abuse, Mistreatment, Neglect, or Misappropriation of Resident Property revealed a section which documented: Abuse Prevention begins with staff screening, using background information before hiring. This includes finger printing and criminal background check per New York State Department of Health regulations. A further review of the Criminal History Record Check Policies and Procedures did not reveal any procedures for Nurse Aide Registry Check. (10 NYCRR 415.4(b)(1)(b))

Plan of Correction: ApprovedDecember 29, 2017

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
The Director of Nursing and Director of Operations (Dietary Director) reviewed the employee record for Cook/Tray Aide #1 to ensure that all pertinent checks were completed (CHRC and Nurse Aide Registry).
Part 2:
The Director of Nursing is to review all new hire employee files to ensure that they have a nurse aide registry check completed, as well as all employees have been checked in the CHRC system.
Part 3:
A pre-employment checklist will be used for every potential employee, which includes the nurse aid registry check. The section of the policy ?Resident Abuse, Mistreatment, Neglect, or Misappropriation of Resident Property? regarding staff screening at hiring will be updated to include procedures for Nurse Aide Registry Check. The Staff Education Coordinator will in-service the policy to those who are responsible for hiring.
Part 4:
The Director of Nursing, Director of Operations, and Staff Educator will be responsible for ongoing compliance. The Director of Nursing with assistance from the Staff Educator will complete audits of new employee files regarding the completion of Nurse Aide Registry checks monthly for 3 months and quarterly thereafter. Results will be discussed at the monthly, then quarterly QAPI meetings for review and action as necessary.
Part 5:
Corrective Action will be completed by (MONTH) 30th, (YEAR).

FF11 483.10(g)(14)(i)-(iv)(15):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.)

REGULATION: §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: January 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #22) of 16 residents reviewed for notification of change, the facility did not ensure that the physician was notified when a resident missed multiple doses of a medication. Specifically, staff did not administer seven doses of an antihypertensive medication used to regulate blood pressure levels. This is evidenced by the following: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/5/17, revealed that the resident was cognitively intact. Physician orders, dated 9/1/17, included [MEDICATION NAME] (antihypertensive) to be administered twice daily at 6:00 a.m. and 8:00 p.m. for a [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interviews conducted on 11/10/17 included the following: a. At 1:21p.m., the Registered Nurse Manager said it is her expectation that the nurses notify medical if a medication is not available. b. At 2:01 p.m., the Physician's Assistant (PA) stated that she was monitoring the resident for elevated blood pressures and should have been notified immediately after the resident missed one dose of [MEDICATION NAME]. The PA stated that the resident notified her of the missed doses of medication on 10/18/17 during a follow-up visit. c. At 4:38 p.m., the Licensed Practical Nurse stated that she did not notify the physician that the medication was not available or administered to the resident. (10 NYCRR 415.3(e)(2)(ii))

Plan of Correction: ApprovedDecember 29, 2017

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
Nurse Manager and Director of Nursing reviewed the MARs for Resident #22 to ensure that no more doses of medication were missed. Resident #22?s medical record was reviewed to ensure that the physician had been notified of any significant changes, medical issues, or missed doses of medication.
Part 2:
The Nurse Manager and Director of Nursing are to review a series of resident?s medical records/charts to ensure that the physician/appropriate parties were notified of any changes per the regulations. Any issues will be reported per protocol and proper parties will be notified.
Part 3:
The facility will update our policy regarding ?Physician Notification?. All licensed nursing staff (RN and LPN) will be re-educated on the policy by the Staff Educator. Through this re-education they will learn their roles and responsibilities related to notifying the physician of significant changes in the residents condition/medical record.
Part 4:
The Director of Nursing (DON) and Assistant Director of Nursing (ADON) are to be responsible for implementation of the policy; and the Nurse Managers (NM) are responsible for ongoing compliance. Audits of the MARs and Resident Medical Records on a sample of Resident?s will be completed by the ADON for monthly for 3 months, then quarterly, to ensure that the physicians have been notified appropriately. Results will be discussed at the monthly, then quarterly QAPI meetings for review and action as necessary.
Part 5:
Corrective Action will be completed by (MONTH) 30th, (YEAR).

FF11 483.45(f)(2):RESIDENTS ARE FREE OF SIGNIFICANT MED ERRORS

REGULATION: The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: January 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #22) of ten residents reviewed for medications, the facility did not ensure that the resident was free from significant medication errors. Specifically, the resident did not receive a blood pressure medication as ordered. This is evidenced by the following: Resident #22 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/5/17, revealed that the resident was cognitively intact. Physician orders, dated 9/1/17, included [MEDICATION NAME] (antihypertensive) to be administered twice daily at 6:00 a.m. and 8:00 p.m. for a [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed that for seven of eight opportunities to administer [MEDICATION NAME] 0.3 milligram (mg) between 10/12/17 and 10/15/17, the nurses' initials were circled. It is documented on the back of the MAR that the reason the medication was not given was that they were awaiting delivery from the pharmacy. A Blood Pressure Monitoring sheet from 10/13/17 through 10/15/17 revealed blood pressure readings of 183/74, 187/78, and 187/68. A review of a physician progress notes [REDACTED]. Blood pressure has been controlled but elevated that day. The plan is to order daily blood pressure checks for a week. A medication reorder sheet from Omnicare Pharmacy revealed a request for refill of [MEDICATION NAME] 0.3 mg was received on 10/15/17 and delivered at 4:00 p.m. on that date. The order for [MEDICATION NAME] 0.3 mg was previously refilled on 09/27/17 and 60 tablets were delivered. When interviewed on 11/29/17 at 2:01 p.m., the resident stated that she missed several doses of her blood pressure medication which she feels caused her blood pressure to rise a few weeks ago. Interviews conducted on 11/30/17 included the following: a. At 1:21 p.m., the Nurse Manager stated that she was made aware on 10/25/17 that the resident missed doses of medication when the resident complained about the incident during a resident council meeting held during the month of October. She said at that time, the staff were not ordering medications as they should be. She said as a result of the incident, a memo was distributed to each floor on the proper procedure for reordering medications. She said when a medication is missed, the reason should be documented on the back of the MAR and in a progress note. b. At 1:40 p.m., the Pharmacist stated [MEDICATION NAME] 0.3 mg was reordered on [DATE] at 7:17 a.m. and delivered at 3:41 p.m. He said the resident's [MEDICATION NAME] was last ordered on [DATE] at 3:00 p.m. and 60 tablets were delivered. The Pharmacist stated that the possible side effects for missing doses of [MEDICATION NAME] could result in elevation of blood pressure. The Pharmacist stated that missing seven doses of [MEDICATION NAME] was a significant medication error. c. At 2:01 p.m., the Physician's Assistant (PA) stated that she was monitoring the resident for elevated blood pressures and should have been notified immediately after the resident missed one dose of [MEDICATION NAME]. The PA stated that she was notified of missed doses of [MEDICATION NAME] 0.3 mg on 10/18/17 by the resident during a follow up visit. d. At 2:26 p.m., the Director of Nursing (DON) stated that she knows the resident has unstable hypertension. The DON stated that she was made aware that the resident missed her medication after the resident complained about the incident to the Social Worker. The DON said she completed a medication error report on 10/25/17. She said that she did not have any documentation supporting the education of staff on reordering medications. At 4:45 p.m., when asked about facility policies regarding the ordering of medications, the DON stated that she did not have any policies regarding the ordering of medications. e. At 4:04 p.m., Licensed Practical Nurse (LPN) #1 said that she faxed a refill request for the [MEDICATION NAME] two days in a row. She said she thinks she notified the supervisor. She said she did not document in the progress notes. LPN #1 said that she thinks the resident's blood pressure went up because she did not receive the [MEDICATION NAME]. f. At 4:38 p.m., LPN #2 stated that she did not give the resident [MEDICATION NAME] 0.3 mg as ordered and circled her initials on the MAR to reflect the medication was not given. She said she did not document that the medication was unavailable or inform the physician. She said the DON asked her about the medication omission a couple days after the occurence. (10 NYCRR 415.12(m)(2))

Plan of Correction: ApprovedDecember 29, 2017

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
Resident #22 was checked by the physician to ensure that there were no ill effects from the significant medication error. A review of Resident #22?s MARs and prescription orders was done to ensure that all medications were at the facility and were being given to the resident at the appropriate times.
Part 2:
Under the direction of the Director of Nursing, the Nurse Managers are to review pharmacy orders and resident records to ensure that all medication is in house and no resident is going without medication. If any issues are found, the physician/PA is to be notified immediately, and the pharmacy to be contacted by the Nurse Manager.
Part 3:
The facility will develop a policy regarding the Ordering of Medications and what to do if a medication is not received in a timely manner. The facility will also develop a document for tracking when medications are not received on time. This is to help ensure that the PA is notified in a timely manner and the resident is free of any significant medication errors. The Staff Educator will be responsible on educating the staff regarding the new policy and tracking document.
Part 4:
The Nurse Managers will be responsible for ongoing compliance under the direction of the Director of Nursing and Assistant Director of Nursing. Nurse managers will track pharmacy orders and note on the newly developed document when pharmacy orders are not received. These trends will be reported monthly for 3 months at the monthly QAPI meeting, and quarterly thereafter.
Part 5:
Corrective Action will be completed by (MONTH) 30th, (YEAR).

Standard Life Safety Code Citations

DEVELOP EP PLAN, REVIEW AND UPDATE ANNUALLY

REGULATION: The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 2, 2018
Corrected date: March 1, 2018

Citation Details

Based on interview and record review conducted during the emergency preparedness plan review, in conjunction with the Life Safety Code Survey completed on 12/4/17, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not update their plan annually. The findings include: A review of the facility's Emergency Management plan revealed that there was no documentation to prove that the plan was constructed using an all hazards approach or risk assessments and no revision dates were listed on the plan. The only plan that had a revision date was the evacuation plan which had a revision date of 8/24/09. In an interview on 12/4/17 at 9:03 a.m., the Staff Educator stated that she did not write the (emergency preparedness) policies, that they were there when she got her position about seven years ago. The Staff Educator also stated that she does not make changes to the policy, they usually only make a change if their contractor tells them to. The Staff Educator stated that she made a new Emergency Manual Book in (MONTH) (YEAR), but that she just transferred the existing policies into the new book. In an interview on 12/4/17 at 9:26 a.m., the Administrator stated that they do not write any of their own emergency preparedness policies, their contractor writes them. If any of the policies were updated, it would have been done by the Staff Educator along with the contractor. In a second interview on 12/4/17 at 11:30 a.m., the Administrator stated that they could not find a risk assessment. (42 CFR 483.73-Emergency Preparedness; 42 CFR: 483.73(a))Based on an interview and record review conducted during an Offsite Post-Survey Review, it was determined that the facility did not comply with emergency preparedness requirements. This is a continuing deficiency from the Life Safety Code Survey of 12/4/17. Specifically, cited issues from the Life Safety Code Survey of 12/4/17 revealed that the facility did not update their emergency preparedness plan annually. This is evidenced by the following: A review of the Statement of Deficiencies for the Life Safety Code Survey of 12/4/17 revealed the facility was cited for areas of noncompliance related to not updating the emergency preparedness plan annually. Further review of the Plan of Correction submitted by the facility and approved on 1/18/18, revealed that by 2/2/18 the facility was to have a contractor update the emergency preparedness plan. During a phone interview on 2/9/18 at 3:30 p.m., the facility Administrator stated that the contractor had not completed the emergency preparedness plan. The Administrator also stated that the surveyor would have to call the contractor to find out when the emergency preparedness plan would be completed. (42 CFR 483.73-Emergency Preparedness; 42 CFR: 483.73(a))

Plan of Correction: ApprovedFebruary 26, 2018

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
The Disaster Plan is reviewed annually at the Leadership Meetings with Russell(NAME)& Associates. If changes need to be made, they are discussed in this meeting and changes are made to the manual. Review of the Disaster Manual shows that there are no dates, which the reviews occur.
Part 2:
It has been determined that when the Staff Educator created a new manual in (MONTH) (YEAR), transferring the old policies into a new book, this was done after a Russell(NAME)Leadership Meeting where polices were reviewed to ensure accuracy for the facility. The policy book is to be reviewed again.
Part 3:
There is another annual review scheduled for (MONTH) (YEAR) with Russell(NAME)and Associates during our annual Leadership Meeting. At this time, the facility will review and update any policies. The facility has also signed a Contract with Russell(NAME)and Associates to review/update Disaster plan on 12/26/17. A risk assessment using the all hazards approach will be done.
Part 4:
The Director of Operations and Staff Education Coordinator will be responsible for ongoing compliance under the direction of the Administrator. Policies will be reviewed as needed and discussed with the QA committee.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR).

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: December 4, 2017
Corrected date: February 2, 2018

Citation Details

Based on interview and record review conducted during the emergency preparedness plan review in conjunction with the Life Safety Code Survey completed on 12/4/17, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the emergency contact information in the New York State Health Commerce System (NYSHCS) database was not completed. The findings are: On 12/4/17 at 10:17 a.m., the Director of Nursing (DON) stated that she was the NYSHCS Administrator for the facility. The DON looked up the contact information for the facility, and there was no contact assigned for the Medical Supplies Receiving Office. The DON stated that she is not sure who that person would be and would have to ask the Administrator. The DON stated that she only updates the NYSHCS as needed, but does not do it monthly or annually. (10 NYCRR: 400.10, 400.10(d); 42 CFR 483.73 - Emergency Preparedness; 42 CFR: 483.73(c))

Plan of Correction: ApprovedDecember 29, 2017

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
Emergency contact information for the Medical Supplies Receiving Office was updated in the Health Commerce System per guidelines.
Part 2:
A review of all other emergency contacts in the NYSHCS was completed and updated.
Part 3:
The emergency contact information will be reviewed monthly to ensure all information is accurately entered and if any changes need to be made. Once verified, the list will be printed and stored to ensure compliance.
Part 4:
The Director of Nursing (HCS Coordinator) will be responsible for ongoing compliance under the direction of the Administrator.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR).

DEVELOPMENT OF EP POLICIES AND PROCEDURES

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 at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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 These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 2, 2018
Corrected date: March 1, 2018

Citation Details

Based on interview and record review conducted during the emergency preparedness plan review, in conjunction with the Life Safety Code Survey completed on 12/4/17, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not utilize risk assessments in their emergency preparedness plan and did not update their plan annually. The findings include: A review of the facility's Emergency Management plan revealed that there was no documentation to prove that the plan was constructed using an all hazards approach or risk assessments and no revision dates were listed on the plan. The only plan that had a revision date was the evacuation plan which had a revision date of 8/24/09. In an interview on 12/4/17 at 9:03 a.m., the Staff Educator stated that she did not write the (emergency preparedness) policies, that they were there when she got her position about seven years ago. The Staff Educator also stated that she does not make changes to the policy, they usually only make a change if their contractor tells them to. The Staff Educator stated that she made a new Emergency Manual Book in (MONTH) of (YEAR), but that she just transferred the existing policies into the new book. In an interview on 12/4/17 at 9:26 a.m., the Administrator stated that they do not write any of their own emergency preparedness policies, their contractor writes them. If any of the policies were updated, it would have been done by the Staff Educator along with the contractor. In a second interview on 12/4/17 at 11:30 a.m., the Administrator stated that they could not find a risk assessment. (42 CFR 483.73-Emergency Preparedness; 42 CFR 483.73(b))Based on an interview and record review conducted during an Offsite Post-Survey Review, it was determined that the facility did not comply with emergency preparedness requirements. This is a continuing deficiency from the Life Safety Code Survey of 12/4/17. Specifically, cited issues from the Life Safety Code Survey of 12/4/17 revealed that the facility did not utilize risk assessments to develop their emergency preparedness plan or update their emergency preparedness plan annually. This is evidenced by the following: A review of the Statement of Deficiencies for the Life Safety Code Survey of 12/4/17 revealed that the facility was cited for areas of noncompliance related to not updating the emergency preparedness plan annually. Further review of the Plan of Correction submitted by the facility and approved on 1/18/18, revealed that by 2/2/18 the facility was to have a contractor update the emergency preparedness plan. During a phone interview on 2/9/18 at 3:30 p.m., the facility Administrator stated that the contractor had not completed the emergency preparedness plan. The Administrator also stated that the surveyor would have to call the contractor to find out when the emergency preparedness plan would be completed. (42 CFR 483.73-Emergency Preparedness; 42 CFR 483.73(b))

Plan of Correction: ApprovedFebruary 26, 2018

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
A review of the plan was done to see if it was constructed using an all hazards approach or risk assessment, and if there were revision dates listed on the plan.
Part 2:
A review of the whole disaster manual is to be done.
Part 3:
The plan will be reviewed and updated by the facility along with Russell(NAME)and Associates. A contract has been signed on 12/26/2017. The Staff Educator will be responsible for educating the staff on any new updates/policies/procedures. A risk assessment will be completed.
Part 4:
The Director of Operations and Staff Education Coordinator will be responsible for ongoing compliance under the guidance of the administrator. The QA committee will review the risk assessment Quarterly and update as needed.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR).

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: December 4, 2017
Corrected date: February 2, 2018

Citation Details

Based on observation, interview, and record review conducted during the Life Safety Code Survey, it was determined that for two of three pieces of Patient Care Related Electrical Equipment (PCREE), the facility did not did not establish testing intervals or policies and procedures for inspection and maintenance. Specifically, a product manual was not available and inspection requirements were not met. The findings include: Observations on 11/30/17 between 8:43 a.m. and 2:57 p.m. revealed the following: a. An Invacare Platinum XL oxygen concentrator labeled as #19 in the third floor Clean Utility room. b. A(NAME)Allyn Spot Vital Signs machine in the second floor Nurses' Station. A review of facility records revealed that the facility did not have a manual for the Invacare Platinum XL oxygen concentrator. Further review revealed that the Product Manual for the(NAME)Allyn Spot Vitals sign machine stated that inspections on the temperature probe, the pulse oximeter cord and accessories for fraying or other damage were to be conducted every three months. In an interview at that time, the Maintenance Director stated that they do not perform any maintenance checks on this equipment. The Maintenance Director also stated that he could not find the product manual for the Platinum XL oxygen concentrator. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 10.5.2.1.1, 10.5.3.1, 10.5.3.1.2, 10.5.6.1.1)

Plan of Correction: ApprovedJanuary 8, 2018

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
Equipment manual was located on the Invacare Platinum XL Oxygen Concentrator. The Director of Maintenance conducted an inspection on the(NAME)Allyn Spot Vital Signs Machine and the Invacare Platinum XL Concentrator to ensure that they were working up to manufacture specifications.
Part 2:
Other Invacare Concentrators and(NAME)Allyn Spot Vital machines in the building will be checked. The Director of Operations and Director of Maintenance will determine what pieces of patient care equipment do not have product manuals and obtain them. The Director of Maintenance will inspect the equipment to ensure that it is working according to manufactory specifications
Part 3:
The facility will develop a log to inspect the patient care equipment in accordance with manufacturers requirements. The policy/procedure Mechanical, Electrical, and Patient Care Equipment will be updated to include directions regarding this log. The Director of Maintenance will educate the maintenance staff to help assist with inspections as needed.
Part 4:
The Director of Operations and Director of Maintenance will be responsible for ongoing compliance.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR).

EP TRAINING AND TESTING

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 2, 2018
Corrected date: March 1, 2018

Citation Details

Based on interview and record review conducted during the emergency preparedness plan review, in conjunction with the Life Safety Code Survey completed on 12/4/17, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not develop and maintain an emergency preparedness training and testing program based on a risk assessment. The findings include: A review of facility annual inservice documents revealed that there was no program for emergency preparedness training. Also, no risk assessments were found with the Emergency Preparedness Plan. In an interview on 12/4/17 at 11:30 a.m., the Administrator stated that there were no emergency preparedness risk assessments. In an interview on 12/4/17 at 1:50 p.m., the Staff Educator stated that they do not have a specific program set up for emergency preparedness. They have monthly inservices that occasionally look at a specific emergency, where they post the information and then the staff read and take a quiz based on the reading. At orientation and the annual inservice they tell staff to look at the disaster manual. The Staff Educator stated that they do not test staff on the procedures in the manual. (42 CFR 483.73 - Emergency Preparedness; 42 CFR: 483.73(d))Based on an interview and record review conducted during an Offsite Post-Survey Review, it was determined that the facility did not comply with emergency preparedness requirements. This is a continuing deficiency from the Life Safety Code Survey of 12/4/17. Specifically, cited issues from the Life Safety Code Survey of 12/4/17 revealed that the facility did not develop and maintain an emergency preparedness training and testing program based on a risk assessment. This is evidenced by the following: During a phone interview on 2/9/18 at 3:30 p.m., the facility Administrator stated that all documentation that the facility had so far was sent in for the Offsite Post Survey Review, but they have not completed their corrections. The Administrator stated that they were working with a contractor to complete the Emergency Preparedness plan. A review of the documentation revealed that the facility had not completed an emergency preparedness training program. (42 CFR 483.73 - Emergency Preparedness; 42 CFR: 483.73(d))

Plan of Correction: ApprovedFebruary 26, 2018

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
A review of the facility in-service documents were done to see if there was a program for emergency preparedness training.
Part 2:
A review and interviews is to be done of past in-services to determine if staff is trained on how to respond to the highest risk emergencies (ex. Fire, missing resident). A review of the orientation in-services, annual in-services, and monthly will be completed to determine what staff is being taught at these times.
Part 3:
The facility will develop an emergency preparedness training and testing program based on a risk assessment with the help of Russell(NAME)and Associates. A contract has been signed on 12/26/2017.
Part 4:
The Staff Education Coordinator will be responsible for ongoing compliance under the guidance of the administrator. The QA committee will review the policies as necessary. QA Committee will also review what in-services are completed each month.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR).

EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 2, 2018
Corrected date: March 1, 2018

Citation Details

Based on interview and record review conducted during the emergency preparedness plan review, in conjunction with the Life Safety Code Survey completed on 12/4/17, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, there was no documented emergency preparedness training for new or existing staff. There was also no annual training program in emergency preparedness. The findings include: A review of facility annual inservice documents revealed that there was no program for emergency preparedness training. In an interview on 12/4/17 at 1:50 p.m., the Staff Educator stated that they do not have a specific program set up for emergency preparedness. They have monthly inservices that occasionally look at a specific emergency, where they post the information and then the staff read and take a quiz based on the reading. The facility does not keep the monthly quizzes, they give them back to staff so that they can see how they did. At orientation and the annual inservice they tell staff to look at the disaster manual. The Staff Educator stated that they do not test staff on the procedures in the manual. (42 CFR 483.73 - Emergency Preparedness; 42 CFR: 483.73(d)(1))Based on an interview and record review conducted during an Offsite Post-Survey Review, it was determined that the facility did not comply with emergency preparedness requirements. This is a continuing deficiency from the Life Safety Code Survey of 12/4/17. Specifically, cited issues from the Life Safety Code Survey of 12/4/17 revealed that the facility did not develop and maintain an emergency preparedness training and testing program based on a risk assessment. This is evidenced by the following: During a phone interview on 2/9/18 at 3:30 p.m., the facility Administrator stated that all documentation that the facility had so far was sent in for the Offsite Post Survey Review, but they have not completed their corrections. The Administrator stated that they were working with a contractor to complete the Emergency Preparedness plan. A review of the documentation revealed that the facility had not completed an emergency preparedness training program, and no documented staff education was provided. (42 CFR 483.73 - Emergency Preparedness; 42 CFR: 483.73(d)(1))

Plan of Correction: ApprovedFebruary 26, 2018

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
A review of employee records was done to see if in-service documentation was kept.
Part 2:
A review and interviews is to be done of past in-services to determine if staff is trained on how to respond to the highest risk emergencies (ex. Fire, missing resident). A review of the orientation in-services, annual in-services, and monthly will be completed to determine what staff is being taught at these times.
Part 3:
Once the Emergency Preparedness plan has been updated, the Staff Education Coordinator will create in-services to train the staff in the procedures. The Staff Education Coordinator will also update the orientation/annual in-services for new/current employees. Documentation will be kept to prove staff was in-serviced/trained.
Part 4:
The Staff Education Coordinator will be responsible for ongoing compliance under the guidance of the administrator. The Staff Educator will report to the QA committee what in-services have been completed each month.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR)

ESTABLISHMENT OF THE EMERGENCY PROGRAM (EP)

REGULATION: The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 4, 2017
Corrected date: February 2, 2018

Citation Details

Based on an interview and record review conducted during the emergency preparedness plan review, in conjunction with the Life Safety Code Survey completed on 12/4/17, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not develop a compliant Emergency Preparedness plan. The findings include. A review of the facility's Emergency Management plan revealed that there was no documentation to prove that the plan was constructed using an all hazards approach or risk assessments. In an interview on 12/4/17 at 9:03 a.m., the Staff Educator stated that she did not write the (emergency preparedness) policies, that they were there when she got her position about seven years ago. The Staff Educator also stated that she does not make changes to the policy, they usually only make a change if their contractor tells them to. The Staff Educator stated that she made a new Emergency Manual Book in (MONTH) (YEAR), but that she just transferred the existing policies into the new book. In an interview on 12/4/17 at 9:26 a.m., the Administrator stated that they do not write any of their own emergency preparedness policies, their contractor writes them. If any of the policies were updated, it would have been done by the Staff Educator along with the contractor. In a second interview on 12/4/17 at 11:30 a.m., the Administrator stated that they could not find a risk assessment. (42 CFR 483.73-Emergency Preparedness; 42 CFR: 483.73)

Plan of Correction: ApprovedDecember 29, 2017

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
While the facility does have a Comprehensive Disaster Plan, a Risk Assessment has not been completed.
Part 2:
The whole disaster plan has been reviewed to determine if there is a Risk Assessment.
Part 3:
The facility will work with the contractor to develop a Risk Assessment. A contract has been signed as of 12/26 to work with Russell(NAME)& Associates.
Part 4:
The Director of Operations and Staff Education Coordinator will be responsible for ongoing compliance under the guidance of the administrator. The QA committee will review the risk assessment Quarterly and update as needed.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR).

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID 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.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC 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 annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 2, 2018
Corrected date: March 1, 2018

Citation Details

Based on interview and record review conducted during the emergency preparedness plan review, in conjunction with the Life Safety Code Survey completed on 12/4/17, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not develop a communication plan. The findings include: A review of the facility Emergency Preparedness plans revealed that Administration or designee will serve as the Public Information Officer and will be responsible for establishing a procedure to notify families. No procedure was included with the plan. In an interview on 12/4/17 at 1:12 p.m., the Administrator stated that Social Work would call families in the event of an emergency and stated that she would assume that is in the Mutual Aid Plan. In an interview on 12/4/17 at 2:08 p.m., the Staff Educator looked through the Emergency Preparedness plan and stated that it was not easily accessible on how to notify families and it probably should be. The Staff Educator was unable to locate the procedure for notifying families in the plan. (42 CFR 483.73 - Emergency Preparedness; 42 CFR: 483.73(c)(8))Based on an interview and record review conducted during an Offsite Post-Survey Review, it was determined that the facility did not comply with emergency preparedness requirements. This is a continuing deficiency from the Life Safety Code Survey of 12/4/17. Specifically, cited issues from the Life Safety Code Survey of 12/4/17 revealed that the facility did not educate staff on their communications plan. This is evidenced by the following: During a phone interview on 2/9/18 at 3:30 p.m., the facility Administrator stated that all documentation that the facility had so far was sent in for the Offsite Post Survey Review. Review of the documentation provided revealed a communications plan, but no proof of staff education with regards to the new communications plan. (42 CFR 483.73 - Emergency Preparedness; 42 CFR: 483.73(c)(8))

Plan of Correction: ApprovedMarch 8, 2018

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
The Emergency Preparedness plan was reviewed and the Administrator or Designee serves as the Public Information Officer who would be responsible for stabling a procedure to notify families. No formal policy was found, but there was an area where it said Social Work team would be responsible for contacting families in case of an emergency.
Part 2:
Team members were interviewed to see if they knew the procedure of what to do to notify families in case of emergency, and it was determined that the staff knew that Administration would designate Social Work and any other employees as needed to notify families.
Part 3:
The facility will establish a procedure to notify families. The Staff Educator will be responsible for educating the staff on any new updates/policies/procedures.
Part 4:
The Director of Operations and Staff Education Coordinator will be responsible for ongoing compliance under the guidance of the administrator. The QA committee will review the policies as necessary.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR).

PLAN BASED ON ALL HAZARDS RISK ASSESSMENT

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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 4, 2017
Corrected date: February 2, 2018

Citation Details

Based on interview and record review conducted during the emergency preparedness plan review, in conjunction with the Life Safety Code Survey completed on 12/4/17, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not conduct risk assessments. The findings include: A review of the facility's Emergency Management plan revealed that there were no documented risk assessments. In an interview on 12/4/17 at 11:30 a.m., the Administrator stated that they could not find a risk assessment. (42 CFR 483.73-Emergency Preparedness; 42 CFR: 483.73(a)(1)(2))

Plan of Correction: ApprovedDecember 29, 2017

This Plan of Correction constitutes a written allegation of compliance for the deficiencies sited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the state and federal law.
Part 1:
While the facility does have a Comprehensive Disaster Plan, a Risk Assessment has not been completed.
Part 2:
The whole disaster plan has been reviewed to determine if there is a Risk Assessment.
Part 3:
The facility will work with the contractor to develop a Risk Assessment. A contract has been signed as of 12/26 to work with Russell(NAME)& Associates.
Part 4:
The Director of Operations and Staff Education Coordinator will be responsible for ongoing compliance under the guidance of the administrator. The QA committee will review the risk assessment Quarterly and update as needed.
Part 5:
Corrective Action will be completed by (MONTH) 2, (YEAR).