Steuben Center for Rehabilitation and Healthcare
July 13, 2018 Certification/complaint Survey

Standard Health Citations

E3BP 402.6(a):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. (a) The provider shall ensure the submission of a request for a criminal history record check for each prospective employee. If a permanent record does not exist for the prospective employee, the Department shall be authorized to request and receive criminal history information from the Division concerning the prospective employee in accordance with the provisions of section 845-b of the Executive Law. Access to and the use of such information shall be governed by the provisions of such section of the Executive Law. The Division is authorized to submit fingerprints to the FBI for a national criminal history record check.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 12, 2018

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for three of ten employee files reviewed for the Criminal History Record Check (CHRC) and three of three agency Certified Nursing Assistants (CNAs), the facility did not ensure the submission of a request for CHRC. Specifically, employees with direct access to and providing care to residents were not screened through the CHRC. This is evidenced by the following: On 7/10/18 from 1:00 p.m. to 1:35 p.m. the surveyor was provided with ten employee files related to the CHRC. The records showed that three agency CNAs were used by the facility in the last four months. The files for the three agency CNAs did not contain any information related to the CHRC. An interview with the Human Resources Director (HRD) revealed the CNAs that come from a staffing agency are not run through the CHRC by the facility and that they provide him with a compliance file. The HRD also stated that he thought the staffing agency did the background checks. He said he does not run a separate CHRC check. (10 NYCRR: 402.6(a))

Plan of Correction: ApprovedAugust 14, 2018

The three individuals identified on 7/10/18 have all been run through CHRC system.

The Human Resource Director will audit all non-licensed personnel files including agency personnel for accurately completed background checks.
Prior to employment the Human Resource Director will conduct background checks on all non-licensed prospective employee's through the New York State CHRC. The results will be maintained in the Human Resource Directors office.
The facilities Criminal Background policy was reviewed with the Human Resource Director by the Administrator on 8/04/2018.
The Human Resource Director will complete monthly audits of all new hires to assure all new employee's have received a criminal background check via the New York State CHRC.
The Human Resource Director will complete monthly audits of all agency and new hire personnel files and report the results through the facilities Quality Assurance Performance Improvement committee. These audits will occur monthly for 6 months . Upon successful results the frequency of the audits will change to quarterly.
The Administrator will be responsible to assure all appropriate employee's including new unlicensed hires and agency receive criminal background checks through the New York State CHRC.

FF11 483.12(b)(1)-(3):DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES

REGULATION: §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95,

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 12, 2018

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for three of ten employee files reviewed, the facility did not properly screen employees for prior findings of abuse. Specifically, the facility did not conduct a Nurse Aide Registry Check prior to staff employment. This is evidenced by the following: 1. A review of facility records on 7/10/18 from 1:00 p.m. to 1:30 p.m. revealed three Certified Nursing Assistants (CNAs) from a staffing agency were used by the facility in the last four months. The files for the three agency CNAs did not contain any information related to abuse screening or a Nurse Aide Registry Check. When interviewed at that time, the Human Resources Director (HRD) revealed the staffing agency provides him with a compliance file and the staffing agency does the background checks. The HRD also stated that he does not run a separate Nurse Aide Registry Check. 2. Review of the facility policy,Abuse/Behavior - Background Checks, updated (MONTH) (YEAR), revealed that the HRD will conduct background checks on persons considered for employment with the facility prior to hire including state Nurse Aide Registry Checks. (10 NYCRR 415.4(b)(1)(ii))

Plan of Correction: ApprovedAugust 14, 2018

1. All agency and employed Certified Nursing Assistants currently working at the facility will be submitted for a criminal background check through the New York State Nurse Aide Registry. The results will be maintained in the employee's personnel file in the Human Resource Director's office.
Prior to employment the Human Resource Director will conduct background checks on all prospective Certified Nursing Aides via the New York State Nurse Aide Registry. The results will be maintained with the employee's personnel file in the Human Resource Directors office.
The facilities CHRC's policy was reviewed with the Human Resource Director by the Administrator on 8/4/2018.
The Human Resource Director will complete monthly Audits of all Certified Nursing Assistants and report the results through our Quality Assurance Performance Improvement committee. These audits will be completed monthly for six months. Upon successful results
the frequency of the audit will change to quarterly.
The Administrator will be responsible to assure the CHRC policy is being accurately and correctly implemented. The date the above correction will be completed is 10/05/2018.

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 12, 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 (Resident #67) of five residents reviewed for [MEDICAL CONDITION] medications, the facility did not ensure that each resident's drug regime was free from unnecessary medications. Specifically, the resident's as needed anti-anxiety medications did not have an indication for use, and were not evaluated and reordered every 14 days by the physician. This is evidenced by the following: Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment, dated 5/21/18, revealed that the resident was cognitively intact and received anti-anxiety and anti-depressant medications. Review of physician orders, dated 6/18/18, revealed the resident was prescribed [MEDICATION NAME] 0.5 milligrams (mg) one time daily for anxiety and 0.5 mg every 24 hours as needed for anxiety. A Pharmacy Medication Record Review, dated 6/19/18, revealed that [MEDICAL CONDITION] medications ordered on an as needed basis are not recommended. The resident's as needed [MEDICATION NAME] should be evaluated and potentially discontinued. The prescriber declined the recommendation and did not want to implement any change. A medical readmission note, dated 6/21/18, and routine visit note, dated 6/26/18, revealed the assessment and plan for the resident's anxiety was to continue the [MEDICATION NAME]. There was no documented rationale in the medical record to continue the of the use of the as needed [MEDICATION NAME]. Review of the Medication Administration Record [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed the resident received one as needed dose of [MEDICATION NAME]. Observations of the resident on 7/11/18 and 7/12/18 did not reveal any signs or symptoms of distress, agitation, or other behaviors. When interviewed on 7/12/18 at 9:56 a.m., a Licensed Practical Nurse stated the resident does have some anxiety at her baseline, has some attention seeking behaviors, and in the past her anxiety has been so bad that it has caused her to go back and forth to the hospital. When interviewed on 7/13/18 at 12:17 p.m., the attending physician stated that the resident's [MEDICATION NAME] is ordered to have a standing dose at night because she is very anxious when trying to go to sleep and an as needed dose available during the day. He said that the resident is up and active in the facility during the day, but may become anxious when she takes a rest in the afternoon. The physician stated that the resident knows that she has the as needed dose available and that seems to relieve some of her anxiety. The physician said that he does not traditionally prescribe as needed [MEDICAL CONDITION] in the nursing home setting unless necessary, and the resident is a unique case. He stated that he was aware of the new regulation and the as needed [MEDICATION NAME] may have been ordered for longer than 14 days, but without looking at the chart he could not say for certain. (10 NYCRR 415.12(1)(2)(i))

Plan of Correction: ApprovedAugust 14, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #67 medication regimen was reviewed. The resident has not utilized the PRN anti-anxiety medication, [MEDICATION NAME], and has not demonstrated any s/s of anxiety requiring additional doses beyond her routine scheduled dose. The provider updated the resident's order to reflect routine daily dose of [MEDICATION NAME] for anxiety and discontinued the PRN order.
In order to identify other residents having the potential to be affected a whole house audit was initiated 8/3/2018 to ensure resident medication regimens were free from unnecessary [MEDICAL CONDITION] medication use, specifically PRN orders without a 14 day limit or documentation from the provider of resident evaluation and indication for the ongoing PRN use.
Measures put in place to monitor include:
LPN, RN and Provider education initiated 7/18/2018 regarding [MEDICAL CONDITION] Drug Usage Practices and Procedures and policy entitled Antipsychotic Medication Use with expected completion on or before 8/31/2018
Audit of resident medication regimens to ensure:
-[MEDICAL CONDITION] medications are only prescribed to treat specific condition as diagnosed and documented in the clinical record
-PRN orders are limited to 14 days unless the provider has documented the rationale and indication for continuation
-PRN orders are not renewed without a provider evaluation of the resident and documentation of the rationale and indication for use.
The audits will be conducted as follows for the above criteria:
Weekly audits x5 weeks (starting 8/3/2018 - Month of August)
Bi-weekly audits x2 weeks (month of September)
Monthly audit until the deficient practice is no longer identified; continue with random audits as needed to ensure continued compliance
The DON will be responsible for the correction and monitoring

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: August 31, 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 two (Residents #69 and #76) of two residents observed for blood glucose testing, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Specifically, the nurse did not properly disinfect the blood glucose testing machine (glucometer) before or after resident use. This is evidenced by the following: Review of the facility policy, Glucometer Cleaning, dated (MONTH) (YEAR), revealed that the glucometer must be disinfected between patient use by wiping it with an Environmental Protection Agency registered disinfecting wipe to reduce the risk of transmitting infectious diseases. 1. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/20/18, revealed the resident had moderately impaired cognition. During an observation on 7/12/18 at 11:50 a.m., the Licensed Practical Nurse (LPN) entered the resident's room with gloves on and used the glucometer to test the blood glucose. Upon completion, the LPN exited the resident's room, removed and discarded the gloves at the medication cart, and placed the glucometer on top of the medication cart. The LPN did not clean the glucometer. 2. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS Assessment, dated 5/25/18, revealed the resident was cognitively intact. In an observation on 7/12/18 at 11:57 a.m., the LPN washed her hands and put on a clean pair of gloves, entered the resident's room and used the glucometer to test the blood glucose. Upon completion, the LPN exited the resident's room, removed and discarded the gloves at the medication cart, placed the glucometer back in its case and into the medication cart without cleaning it. In an interview on 7/12/18 at 12:19 p.m., the LPN stated that she should have wiped the glucometer down between residents but she did not. She said that she usually cleans the glucometer with bleach wipes that are located at the nurses' station. The LPN said if she could not get to the bleach wipes then she would wipe the glucometer down with an alcohol pad. When interviewed on 7/13/18 at 12:02 p.m., the Assistant Director of Nursing stated that she would expect the nurse to clean the glucometer in between residents using the approved bleach wipes. She said that she would not expect the nurse to use an alcohol wipe unless they were in a pinch. (10 NYCRR 415.19(a)(3)(b))

Plan of Correction: ApprovedAugust 4, 2018

No residents were affected by the deficient practice
LPN/RN review, verbalization and demonstration of the Glucometer Cleaning Policy initiated 7/12/2018 with completion expected on or before 8/31/2018
To demonstrate LPN/RN knowledge, competency and compliance of Infection Control when performing resident glucose testing, random weekly audits of active LPN/RN staff will be conducted starting 8/6/2018 with expected completion on or before 8/31/2018
All findings will be reported to the QAPI Committee for review and comment.
Audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI Committee
The DON will be responsible for correction and monitoring

E3BP 402.5(c):REQUIREMENTS BEFORE SUBMITTING A REQUEST FOR

REGULATION: Section 402.5 Requirements Before Submitting a Request for a Criminal History Record Check. ...... (c) The provider shall obtain the signed, informed consent of the subject individual in the form and format specified by the Department which indicates that the subject individual has: (1) been informed of the right and procedures necessary to obtain, review and seek correction of his or her criminal history information; (2) been informed of the reason for the request for his or her criminal history information; (3) consented to the request for a criminal history record check; and (4) supplied on the form a current mailing or home address.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: July 13, 2018
Corrected date: September 12, 2018

Citation Details

Based on an interview and record reviews conducted during the Recertification Survey, it was determined that for ten of ten employee files reviewed for the Criminal History Record Check (CHRC) the facility did not obtain or properly complete the signed consent form to initiate a CHRC. Specifically, the DOH-102 form was not signed and dated by the authorized person, or was not completed by the employee. This is evidenced by the following: On 7/10/18 from 1:00 p.m. to 1:35 p.m. the surveyor was provided with eight employee files related to the CHRC. The records for six of the eight files reviewed lacked a completed DOH-102 consent form. An interview with the Human Resources Director revealed the forms are given to the prospective employees to fill out with their initial paperwork, but he does not always get them back. Further interview revealed Certified Nursing Assistants (CNAs) that come from a staffing agency are not run through the CHRC by the facility. Additional record review revealed that three agency CNAs were used by the facility in the last four months. Review of the DOH-102 consent forms that were available, revealed Section 3 (Agency Authorized Person Information) was neither signed or dated. A review of the facility policy, CHRC/Fingerprinting-NY, date originated and date revised were blank, revealed the applicant will be asked to sign a statement disclosing any prior finding of patient or resident abuse, or conviction of a crime and specific written and signed authorization from the prospective employee. (10 NYCRR: 402.5(c))

Plan of Correction: ApprovedAugust 14, 2018

All Certified Nursing Assistants personnel files will be audited by the Human Resources Director for completed, signed and dated by the authorized person.
All prospective Certified Nursing Assistants including agency that Steuben Center contracts with will have completed DOH-102 forms and will be submitted CHRC for a criminal background check.
The facilities criminal background check policy was reviewed with the Director of Human Resources on 08/04/2018.
The Human Resource Director will complete monthly audits of all certified nursing assistants personnel files for a completed DOH-102 form. The results of this of this audit will be presented to the Quality Assurance Performance Improvement committee. The audit will be completed monthly for six months. Upon successful outcomes the audit will be completed quarterly.
The Human Resource Director will complete monthly audits of all appropriate personnel files to assure that DOH-102 form is completed, dated and signed by the authorized person. The results of the audit will be presented to the monthly Quality Assurance Performance Improvement committee. These audits will be completed monthly for the first 6 months. Upon successful outcomes, the frequency of the audit will change to quarterly.
The Administrator will be responsible to assure that the facilities CHRC policies are correctly followed and appropriately completed.

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: October 25, 2018
Corrected date: N/A

Citation Details

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not maintain compliance with Subpart 713-3, Standards of Construction for Nursing Homes completed or approved between (MONTH) 2, 1990 and (MONTH) 31, 2010. Specifically, rooftop exhaust outlets that were not located at least 25 feet away from air handling unit intakes. This is evidenced by the following: 1. Observations on 7/9/18 at approximately 10:05 a.m. revealed two roof top exhaust outlets were less than 25 feet from nearby air handling units. An interview with the Interim Environmental Services Director revealed there had been no changes to the roof air handlers and exhaust vents to his knowledge. In an interview with the Administrator on 7/10/18 at 1:42 p.m., he said he thought they had three years from the last survey to fix the issue. 2. After the facility was originally constructed and occupied in 2008, the facility requested and was granted a waiver for this condition by the NYSDOH Bureau of Architecture and Engineering Facilities Planning on 5/21/18. Further record review revealed the dishwasher room exhaust fan EF-13 is 13 feet from air intake KSU-1, and exhaust fan on KSU-1 kitchen hood is 11 feet 6 inches from air intake KSU-1. In 2014, the facility was purchased by new owners, and there was no documentation to show that the facility had re-applied for the waiver. (10 NYCRR: 713-3.24(d)(2)(i); 2010 FGI: 4.1-8.2.1; Part 6 ASHRE Standard [PHONE NUMBER]: 6.3.1)Based on record review conducted during the Offsite Post-Survey Revisit completed on 10/25/18, it was determined that the facility did not maintain compliance with Subpart 713-3, Standards of Construction for Nursing Homes completed or approved between (MONTH) 2, 1990 and (MONTH) 31, 2010. Specifically, the facility did not complete their written Plan of Correction for the Recertification Survey completed on 7/13/18, and rooftop exhaust outlets were not located at least 25-feet away from air handling unit intakes. The findings are: 1. A review of the Plan of Correction submitted by the facility from the survey of 7/13/18 revealed the facility statement included: As this condition is based on original construction, Steuben Center will apply and submit an application for a waiver from the Bureau of Architecture and Engineering Facility's Planning as this presents an undue financial burden on the facility. The areas we will request relief from are as follows. The EF-13 exhaust fan being too close to air intake KSU-1. The exhaust fan on KSU-1 kitchen hood and air intake KSU -1. The Administrator will be responsible to assure the waiver is filed with the Bureau of Architecture and Engineering Facilities Planning. The completion date listed for the Plan of Correction was 9/12/18. 2. There was no documentation provided by the Administrator to show that a waiver application was submitted to the Bureau of Architecture and Engineering Review. Further review of the Bureau of Architecture and Engineering Waivers Data System on 10/9/18 revealed no indication of a waiver submitted for review by Steuben Center for Rehabilitation and Healthcare. (10 NYCRR: 713-3.24(d)(2)(i); 2010 FGI: 4.1-8.2.1; Part 6 ASHRE Standard [PHONE NUMBER]: 6.3.1)

Plan of Correction: ApprovedNovember 6, 2018

As this condition is based on original construction, Steuben Center will apply and submit an application for a waiver from the Bureau of Architecture and Engineering Facilities Planning as this presents an undue financial burden on the facility. The areas we will request relief from are as follows.
The EF-13 exhaust fan being too close to air intake KSU-1
The exhaust fan on KSU-1 kitchen hood and air intake KSU -1
The Administrator will be responsible to assure the above mentioned waiver is filed with the Bureau of Architecture and Engineering Facilities Planning.

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: July 13, 2018
Corrected date: September 12, 2018

Citation Details

Based on observations, 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 facility did not fully update the Emergency Preparedness Plan (EPP) annually. The findings are: 1. Observations and record review on 7/10/18 at 11:15 a.m. revealed the fire and disaster manual located on a shelf at the second floor Waneta Unit nurses' station was titled, 'Steuben County Emergency Management Plan,' and showed revision dates of (MONTH) of 2008 and (MONTH) of 2010. A page just inside the front cover listed emergency contact information for the Directors of Maintenance and Environmental Services, who had not been employed at the facility in several years. The fire plan in the binder listed the last revision date as (MONTH) of 2014. Further review of similar binders located at the Lamoka and Keuka nurses' stations revealed the same plans with the same dates and listing the facility as 'Steuben County Health Care Facility'. 2. A review of the emergency preparedness binder provided by the Administrator on 7/11/18 at 10:35 a.m. revealed the plan was dated (MONTH) 2008 and initialed as revised (MONTH) 2010. The full building evacuation plan was dated (MONTH) 2010, the fire plan was dated (MONTH) 2014, specific disasters other than fire were dated (MONTH) 2008, emergency lists and phone numbers for vendors, contractors, and agencies were dated (MONTH) 2008. Additionally, the evacuation stopover point was listed as the Steuben County Civil Defense Building. An interview with the Administrator at that time revealed this is not the stopover point and that it had been changed to Bath Central School. (42 CFR 483.73 - Emergency Preparedness; 42 CFR: 483.73(a))

Plan of Correction: ApprovedAugust 14, 2018

The Emergency Preparedness Plan will be updated to reflect the most current and updated policies and procedures being followed by Steuben Center. All Emergency Preparedness and Life Safety Manuals throughout the facility will reflect the most current updated policy and procedures in place.This update will include the transition to a new stop over point the Bath High School.
Upon completion of updating the Emergency Preparedness Plan, The Director of Engineering will review the Emergency Preparedness manual to assure all relevant information is accurate, current and up-to-date.
Upon completion of updating the Emergency Preparedness Plan the Director of Engineering will present the manual to the Quality Assurance Performance Improvement committee. On an annual basis the plan will be reviewed by the Director of Engineering and presented to the Quality Assurance Performance Improvement Plan.
The Director of engineering will be provided access to the Health Commerce System in order to keep abreast of changes at the DOH level that would affect our existing plan. The Director of Engineering will also attend educational training throughout the year to Regarding Life Safety and Emergency Preparedness.

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: October 25, 2018
Corrected date: December 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for two (lift and alternating pressure pump) of four types of patient care related electrical equipment, the facility did not provide maintenance in accordance with manufacturer's specifications. Specifically, lifts were not inspected annually, and there were no inspections/maintenance procedures performed for alternating pressure pumps. The findings are: 1. Observations on 7/10/18 at approximately 11:15 a.m. revealed an 'Arjo' brand sit-to-stand lift (labeled K4) located outside room [ROOM NUMBER]. Further review of the manufacturer's specifications for the lift revealed a preventative maintenance schedule and minimum recommendations in the form of a checklist (page 22). The actions (11 total) marked on the checklist with an 'S' are to take place every 12 months and must be carried out by qualified personnel, using correct tools and knowledge of procedures (per the manufacturer). The facility provided completed monthly work orders for inspections of lifts, however, there was no documentation to show that the 12 month inspection was performed. Subsequent interviews with the Interim Director of Environmental Services (IDES) and the Administrator revealed they used to have a third party company come out to inspect the lifts, but were not sure when the last time they came in. 2. Observations on 7/11/18 from 10:30 a.m. to 10:50 a.m. revealed a 'Meda Cure Alter Peutic' brand alternating pressure pump (AAP) on the footboard and mattress of the bed in Resident room [ROOM NUMBER]. Additional pressure pumps were also observed at the following locations: Rooms #250 (B-bed), #257 (B-bed), #217 (B-bed), #145 (A-bed), #150 (A-bed), #120 (B-bed), #118 (B-bed), and #115 (B-bed). A review of the manufacturer's specifications for the pumps (page 15) revealed preventative maintenance including, but not limited to the following: check and clean the air filter monthly, check air hoses, check for wear and damage, check the power cord and plug, check power indicators. There was no documentation provided by the facility to show preventative maintenance was occurring for the AAPs. Interview with the IDES revealed the AAPs are rentals and not facility owned. 3. A review of the facility policy P&P-M-2, last revised 11/13, and titled: 'Steuben County Health Care Facility Preventative Maintenance Schedules' revealed manufacturer's specifications and recommendations were not mentioned or referred to in the policy. The 2012 edition of NFPA 99, Health Care Facilities Code, requires: Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 10.5.2.1.1, 10.5.3.1.2)Based on record review conducted during an Offsite Post-Survey Revisit completed on 10/25/18, it was determined that for two (lift and alternating pressure pump) of four types of patient care related electrical equipment, the facility did not provide maintenance in accordance with manufacturer's specifications. Specifically, the facility did not complete their written Plan of Correction for the Life Safety Code Survey completed on 7/13/18, lifts were not inspected annually, and there were no inspections/maintenance procedures performed for alternating pressure pumps. The findings are: 1. A review of the Plan of Correction submitted by the facility from the survey of 7/13/18 revealed the facility statement included: All patient care-related electrical equipment in house will be identified and inspected according to the manufacturer's recommendations by a qualified outside third party. All patient care-related electrical equipment brought into the facility will have verification of inspection or will be inspected prior to being released to the floors. All patient related electrical equipment will be inspected according to the manufacturer's recommendations by an authorized third party. The results of the audit will be maintained in the Director of Engineering's office. The Director of Engineering will be responsible to assure that all Patient Care Electrical Equipment will be inspected according to the manufacturer's recommendations. The completion date listed for the Plan of Correction was 10/5/18. 2. There was no documentation provided by the Administrator or Director of Engineering to show that all patient care-related electrical equipment was inspected according to manufacturer's recommendations by a qualified third party. There was also no documentation to show that a patient care-related electrical equipment audit was performed. The 2012 edition of NFPA 99, Health Care Facilities Code, requires: Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 10.5.2.1.1, 10.5.3.1.2)

Plan of Correction: ApprovedNovember 12, 2018

All patient care related electrical equipment in house will be identified and inspected according to the manufacturers recommendations by a qualified outside third party.
All patient care related electrical equipment equipment brought into the facility will have verification of inspection or will be inspected prior to being released to the floors.
All patient related electrical equipment will be inspected according to the manufacturers recommendations by an authorized third party.
On a monthly or when appropriate basis the Director of Engineering will present the above referenced inspections to the Quality Assurance Performance Improvement committee.
The results of the patient care electrical equipment audit will be maintained in the Director of Engineering's office.
The Director of Engineering will be responsible to assure that all Patient Care Electrical Equipment will be inspected according to the manufacturers recommendations.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2018
Corrected date: December 20, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for three (ground, first, and second floors) of three resident use floors, the facility did not properly maintain means of egress. Specifically, the facility did not properly inspect firerated doors. The findings are: 1. During a review of facility records on 7/9/18 at 2:09 p.m., the Interim Director of Environmental Services stated that he was not aware of any fire door inspections. Further record review on 7/11/18 at 8:38 a.m. revealed a preventative maintenance work order completed by facility maintenance staff on 6/13/18 for all doors in the facility for the following items: check operation, closure, magnets, hardware, and rubber seals. The work order did not address or reference all NFPA 80 requirements for annual fire door inspections. 2. Observations throughout the facility on 7/11/18 revealed the following doors and frames showing a metal tag with a firerating: center stairwell doors, cross corridor double doors, exit stairwell doors, and laundry room doors. The doors and frames listed fire resistance ratings ranging from 20 minutes to 90 minutes. The 2010 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives, requires fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the Authority Having Jurisdiction. Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 7.1.3.1, 8.3.3.1; 2010 NFPA 80: 5.2.1, 5.2.4.1, 5.2.4.2; CMS S&C 17-38-LSC)Based on record review conducted during an Offsite Post-Survey Revisit completed on 10/25/18, it was determined that for three (ground, first, and second floors) of three resident use floors, the facility did not properly maintain means of egress. Specifically, the facility did not complete their written Plan of Correction for the Life Safety Code Survey completed on 7/13/18, and fire-rated doors were not inspected annually per NFPA 80. The findings are: 1. A review of the Plan of Correction submitted by the facility from the survey of 7/13/18 revealed the facility statement included: The facility will engage a qualified outside third party agency to inspect all of the facility's fire doors according to the 2010 edition of NFPA 80 standard for fire doors by 10/5/18. The fire doors will be inspected annually by an outside third party agency qualified to inspect the doors according to 2010 edition of NFPA 80. A written record of the inspection shall be signed and maintained for review by the authorities having jurisdiction. The Director of Engineering will also attend any relevant educational programs dealing with Life Safety. The completion date listed for the Plan of Correction was 10/5/18. 2. There was no documentation provided by the Administrator or Director of Engineering to show that the fire doors had been inspected, nor was a written record of the inspection provided for review. Additionally, there was no documentation provided to show that the Director of Engineering attended any relevant educational programs. The facility provided a proposal and quote by a vendor (dated 9/18/18) to inspect fire and smoke doors; however, the proposal was not signed. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 7.1.3.1, 8.3.3.1; 2010 NFPA 80: 5.2.1, 5.2.4.1, 5.2.4.2; CMS S&C 17-38-LSC)

Plan of Correction: ApprovedNovember 6, 2018

The facility will engage a qualified outside third party agency to inspect all of the facilities fire doors according to the 2010 edition of NFPA 80 standard for fire doors by (MONTH) 5th (YEAR).
The fire doors will be inspected annually by an outside third party agency qualified to inspect the doors according to 2010 edition of NFPA 80. A written record of the inspection shall be signed and maintained for review by the authorities having jurisdiction.
The Director of Engineering will have access to the Health Commerce System to remain current with any new Life Safety policies and procedures. The Director of Engineering will also attend any relevant educational programs dealing with Life Safety.
On an annual basis the Director of Engineering will present the fire door inspection results to the Quality Assurance Performance improvement committee.
The Director of Engineering will be responsible to maintain and update all Life Safety manuals.