Ozanam Hall of Queens Nursing Home Inc
January 23, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 29, 2018

Citation Details

Based on observation, and staff interview the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, cold foods stored on the unit were not served at appropriate temperatures. This was observed on unit 4 on 1/18/18 at approximately 12 PM. The findings are: On 1/18/18 at 12 PM the surveyor did food temperatures with dietary aide on Unit 4. The following was the observations.: 1) applesauce 53 degrees 2) chocolate pudding 55 degrees An interview was conducted with the dietary worker after temperatures were checked. The food service worker could not provide information regarding what the appropriate temperatures should be for storing and serving food. She had ask her manager. The manager came up to the fourth floor and stated that they would call down for applesauce and chocolate pudding. Another observation was done on 1/18/18 at 12:35 PM and applesauce was 39 degrees and the chocolate pudding was 53 degrees. The dietary worker stated ,I guess 53 is ok. The Assistant Director (AD) of Food Service was interviewed and stated that the appropriate temperature of the chocolate pudding should be 40 degrees or below. The AD stated that the process to ensure cold foods are at appropriate temperature was to put the cold foods in the freezer for a half an hour to 45 minutes, prior to meal service. The Food Service Director (FSD) on 1/18/18 around 2:30 PM. The FSD said that the last time the worker was inserviced on proper temperatures was on 8/2/16. The FSD stated that employees should receive inservice at least on a yearly basis. 415.14(h)

Plan of Correction: ApprovedFebruary 15, 2018

Element 1
? On 1/18/18 it was noted on Unit 4 that two (2) cold items were at a higher temperature than the recommended temperature. The Assistant Director of Food Service, present on the unit, notified the Main Kitchen and new cold dessert items were sent to the unit.
Completed 1/18/18
? The Assistant Director of Food Service gave an in-service to the Pantry Aide on the unit as to the appropriate food temperature. Completed 1/18/18
Element 2
? Food Service Supervisors on the other units verified that the cold food temperatures were within the appropriate range. Completed 1/18/18
? The Director of Engineering was notified that the cold well on unit 4 was not functioning properly. A Maintenance person responded to the unit and the coils were vacuumed prior to the next meal. Ice was added to the cold well until the procedure was completed. Completed 1/18/18
Element 3
? The Director of Food Service checked the cold wells on all units and notified Engineering Department if the cold well was not at the appropriate temperature. Ice was added to the cold well until the procedure was completed. Completed 1/18/18
? The Director of Engineering/Designee was able to repair all cold wells except for Unit 5.
? That cold well will be repaired and until then ice will be used. Completed by 2/16/18.
? The Director of Food Service reviewed and revised the process for preparing food items in the Main kitchen before delivery to the units. Completed 1/18/18
? Food Service Supervisors will complete the following tasks on a daily basis
- Review of the cold well refrigeration temperate logs
- Review of the HACCP logs to ensure that food temperatures are being met and maintained as required.
- Review of the taste panel chart which records the food temperatures that will now include pantry desserts and sandwiches.
- FSD/Designee will provide annual in-services to all dining service staff on hot and cold holding temperatures with a competency test provided.
Completed 2/13/18
Element 4
? Quality Assurance refrigeration audit will be initiated and completed related to thermometers and temperatures on all refrigeration/freezers and cold wells. Results will be forwarded to the QA Committee monthly until 100% compliance is achieved. Frequency of reporting will be
re-evaluated at that time.
? Quality Assurance activity will be initiated related to Dietary staff participation in specific dietary, as well as all mandatory education programs. It will be completed on two (2) topics per month to ensure 100% attendance by staff. Results will be forwarded to the QA Committee monthly until 100% compliance is achieved. Frequency of reporting will be re-evaluated at that time.
Completed by 3/22/18

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: Actual harm has occurred
Citation date: January 23, 2018
Corrected date: March 29, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recordsreview and interviews conducted during re-certification and abbreviated survey the facility did receive adequate supervision to prevent accidents. Specifically: A CNA (Certified Nurses Assistant) did not follow the resident's plan of care when assisting the resident in transfering from bed to wheel chair. As a result the resident fell from the bed, and obtained a laceration to the face. This was evident for 1 resident reviewed for accidents out of a sample of 35 sampled residents Complaint #NY 908 1) Resident #475 is a [AGE] year-old admitted to the facility for short term rehab on 12/27/17, with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) 3.0 assessment dated [DATE] documented the resident's cognition is intact with a Brief Interview of Mental Status (BIMS) of 13. Alert and oriented, confusion and some trouble with recall. The resident was totally dependent on staff with chair to bed/bed to chair transfers and required substantial/maximum assistance sit to laying, lying to sitting, sitting to standing. The Comprehensive Care Plan (CCP) dated 12/27/17 for Resident #475 documented all care and goals for the resident. Specifically, the CCP for Falls/stated: The resident is at risk for falls related to confusion, gait/balance problems and unaware of safety needs. The Certified Nursing Assistant Assignment Record(CNAAR) for the resident documented the resident required extensive assistance by 2 people for showers, bed mobility, turning and repositioning, dressing, transfers, to move between surfaces as necessary, and for toileting. Occupation/Physical Therapy Plan of Care/ Initial assessment dated [DATE] documented treatment for [REDACTED]. It also revealed she was alert and oriented to person and place only. Moderate cognitive impaired status with cognition/following commands at 51-70 percent ability and required frequent direction in occasional situations. Recall, safety/judgement were marked at 31-50 percent ability. Resident was at maximum assistance required for all Activities of Daily Living (ADL), self-care with hygiene, dressing, grooming, toileting, functional transfers, shower/tub/wheel chair/toilet, bed mobility: sit/stand, wheel chair/wheel chair assist. The facility's forms titled Quality Assurance Fall Investigation documented that the resident had various falls while at the facility. The resident had two documented falls on on 12/29/17. The first fall was at 4:40 AM where resident was observed by staff sitting on the floor by the foot of her bed and resident indicated she was trying to get out of bed to get an emery board for her nails and attempted to get herself out of the bed. No injury. The second fall was at 8:30 AM and caused by a CNA who attempted to transfer the resident without the assist of another person,which resulted in the resident falling face down and sustaining a laceration between the eyebrows size 1.4cm x 0.2cm, treated with Steri Strip per doctor's orders, with neurological checks performed every 4 hours for 48 hours. The facility summary of investigation report dated 01/03/2018 revealed resident with a history of subdural hematoma status [REDACTED]. The resident required two-person assistance for transfers and ambulation, close supervision and anticipation of needs to prevent further falls. The Employee file/records of CNA#1 revealed date of hire to be 05/08/2017. It contained all pertinent paperwork including job description, trainings and competencies. The Policy on Incident/Accident dated 2/2017 documents that all incidents shall be reported, describing the procedure and protocol required by regulations and facility guidelines. It also describes how to identify falls, their occurrence, assessments and care plan with immediate and new interventions required, including falls risk assessment and falls reduction with family/representative to participate in the planning. On 01/22/18 at 4:26 PM a telephone interview with CNA#1 was conducted. CNA #1 said she was a floater for that day (temporarily assigned to different units). She said that she was asked to assist another resident first and had given someone a shower. A staff member called her asking her to go in to the room, saying resident's spouse wanted her to get up to use the bathroom. CNA#1 stated she went into the resident room and spouse was in there talking to resident and told her the resident had just come in the night before. CNA#1 said he began telling her about an incident the resident suffered at home and the hours before the shift change. The spouse then stepped out the room while she began assisting resident. The resident was sitting at the edge of bed and the CNA let her go to get the wheel chair, turned for a split second and the resident fell face down. The CNA immediately called for assistance, the resident was picked up off the floor with two staff members, evaluated and treated, according to policies and procedures of the facility. The CNA admitted she did not look at the CNAAR Care plan book at her start of shift which is her guide on resident care and their needs. The CNA stated she did not work on a specific floor in the facility saying she was a floater/temp staff member and was not familiar with the residents. She stated that the wait for a second person can be cumbersome and she was trying to get ahead of her work. On 01/23/18 at 09:59 AM an Interview was conducted with RN #1 (Registered Nurse) a supervisor. RN#1 stated CNA #1 immediately notified staff about the accident and followed policies and procedures. RN stated that when she entered the resident's room she saw the resident lying face down and there was blood visible on the resident. They picked up the resident from the floor, and provided immediate care and treatment to the resident. The spouse returned to the room as well and was upset but staff tried to maintain calm with appropriate interventions initiated for resident and spouse. RN #1 stated it was learned during the investigation, that CNA#1 did not look at the CNAAR assignment book concerning resident care and began transferring this resident without knowing the resident's care plan; which specified two-person assist on those written orders. This omission contributed to the accident. The RN and Director of Nursing DON immediately investigated the incident and had CNA#1 perform role play to understand what happened. CNA#1 was removed off the unit and terminated immediately after the incident and investigation. The RN said the CNA was usually excellent in all care rendered prior to this incident and it was her only incident. RN#1 stated she was the person who completed her two-month evaluation/competencies and the CNA#1was aware of all her job responsibilities and duties including looking at the assignment book first before performing any resident care. On 1/23/18 at 10:36 AM, an interview with the DOn Director of Nursing was conducted. She was in the facility on that day and was called to the unit concerning the fall. She conducted the investigation with the RN Supervisor asking CNA for role play to understand what happened and the aide said the resident was at edge of bed she went to get wheel chair and the resident fell forward on to floor, cutting her head. Everyone was notified immediately by CNA according to protocol and the resident was picked up and assessed by RN. DON reports the CNA was a temporary CNA/floater and the role play done during investigation with supervisor RN present corroborated with RNs account. The resident asked to go to bathroom and her spouse said she can do it by herself, and he left the room, the CNA assisted the resident to sitting position at the bedside, left her dangling while she reached for the wheel chair, but the resident went down immediately. The CNA failed to get report before going to perform duties on the unit. She did not follow the resident's plan of care. After the immediate intervention and investigation, the CNA was terminated and relieved from her duties at the facility. On 01/23/18 10:43 AM an interview was conducted with the spouse. He said the resident was sleeping and was unable to come to the phone. He stated the second day she was there she was in the room on 10th floor and the CNA went to provide help in dressing resident, He said he told the CNA that she cannot stand alone, at hospital was on a 1:1. He said he left the room to give privacy and walked 10 feet away into the hallway and when he returned he saw the resident lying face down in a pool of blood. He stated he did not witness the fall but that she hit the foot rest from the wheel chair that was on the floor. He reporeds she has a scar between the eye brows from one fall and above the eye brow from a second fall on a different floor. Resident had numerous falls. He said the first one was at home before admission and the others while at the facility. The first one at the facility on the 10th Floor at 4:40am then 8:30 AM on the same day and another serious one was on the 3rd floor 8:30 PM or 9:00 PM unsure of the dates, but was sutured at 5:30 AM the next day at the hospital. The resident was discharged to her home from the facility on 01/14/15. After speaking to the spouse, a brief interview was conducted with the DON (Director of Nursing) on 01/23/18 at 11:13 AM. The DON provided a copy of all incidents/occurrence and investigation for this resident and the information conferred with the information concerning falls that the spouse referred to during the telephone interview but the DON stated that the Resident had multiple falls that was related to cognitive impairment sustained after her initial fall at home and with resident becoming restless and with poor impulse control. The Resident was not exhibiting the understanding that she required assistance. Her BIMS was 13 with some impaired cognition that was undetermined and being reassessed. New interventions were put into place and the spouse was included in the care planning to avoid further falls. 415.12(h)(1)

Plan of Correction: ApprovedFebruary 15, 2018

I Immediate Corrections:
Resident # 475
1. As per facility Policy, the DNS conducted a complete and thorough investigation relative to this resident?s fall and sustained injuries. Based on the investigation, the following corrections were immediately implemented:
* The resident was provided with immediate assistance, first aid, and was subsequently provided with steri-strips for care of the facial laceration.
* The resident was evaluated by the NP and placed on Neuro ?checks and same were added to the comprehensive care plan. The NP documented a progress note relative to this evaluation.
* The DNS and RN supervisor interviewed the CNA and did a reenactment of the fall with the CNA and ascertained she failed to review the CNA directives nor follow the plan of care for 2 person transfer
* Based on the investigative findings, the CNA was terminated from the Facility
* The DNS notified the DOH as per requirements on 12/29/17.
* The DNS held a special review care plan meeting due to resident?s history of multiple falls and new interventions were added to prevent falls including that the Charge Nurse will review the plan of care with assigned CNAs prior to providing assistance daily and Q shift.
* The Plan of Care summary was reviewed with the Resident?s husband on 12/29/17.
II. Identification of Other Residents:
1. The DNS reviewed all Accidents and Incidents over the past quarter to ensure that the plan of care was followed for all Residents; with a concentration on ADL assistance required and ADL assistance provided.
2. There were no additional quality issues identified from this review, and all investigations were compliant per policy.

3. The DNS and RN Supervisors compiled a list of all Residents who require a 2 person transfer.
4. This list was used by the RNs and Charge Nurses to perform on site visual rounds during care to observe the provision of ADL assistance to ensure the plan of care is consistently followed. Any quality issues identified from these rounds will have immediate onsite corrections to ensure provision of care, and prevention of falls/accidents.
5. Any corrective actions implemented will be documented and reviewed by the DNS to ensure ongoing competency in provision of ADL care by our CNA staff.
6. The visual rounds will be documented on a Rounds audit tool to track compliance with providing ADL assistance as per plan.
III. Systemic Changes:
1. The Administrator has contracted with Ruth West RN, BS from Consistent Compliance, LLC to assist the Facility with a Directed Plan of Correction and Directed Inservice Education.
2. The DNS has reviewed the Policy and Procedures for Accident Prevention and Intervention and found same compliant.
3. The DNS has also reviewed the Policy on the CNA care plan and assignment relative to ADL assistance and revised the policy to add a directive that requires the Charge Nurse to review the plan of care with any new CNA or float CNA to ensure awareness and provision.
4. All RN Supervisors and Charge Nurses were alerted to this directive by the DNS at the Morning Meeting, and in shift to shift reports for immediate implementation.
5. The Charge Nurses will be responsible to review the plan of care for ADL assistance; relative to any change in the plan as well as to review with float CNAs or newly assigned CNAs to ensure consistent compliance with ADL assistance.
6. The Facility held a Special Review QA Meeting on 2/13/18 which was facilitated by the Administrator and DNS.
7. The QA meeting discussed the Accident involving Resident #475, as well as the quality issues and causative factors identified which was the CNA not following the plan of care for 2 person assisted transfers.
8. In addition, the QA Committee was alerted to triggers that may alert staff that quality issues could occur as well as a plan for immediate and ongoing corrective actions; and systems for monitoring those corrective actions.
9. A copy of the Agenda and Attendance was filed for reference and validation in the Plan of Correction Book.
10 a. The Consultant Ruth West RN, BS has developed an educational Lesson Plan relative to compliance with F689, and prevention of Accidents. The Lesson Plan will have a concentration on ?Reviewing the Plan of Care? and? Following the Plan of Care?. The Lesson Plan is attached for DOH review and acceptance.
b. The Education will be provided to all Nurses and CNAS as follows:
2/19/18 Monday: 10:30am, 2pm, 3:30pm, 5pm, 12mid
2/20/18 Tuesday: 10:30am, 2pm, 3:30pm, 5pm, 12mid
2/21/18 Weds: 10:30am, 2pm, 3:30pm, 5pm, 12mid
c. The educational program will be video taped for provision to off shifts and absent staff to ensure compliance with Directed Inservice requirements.
d. The Attendance and Lesson Plan will be retained for reference and validation of education provided.
IV. QA Compliance:
A 1. The DNS in conjunction with the Consultant has developed a Visual observation audit tool to track the provision of care by CNAS specific for both following the plan of care and accident prevention.
2. Audits will be done by the RNs/Charge Nurse on each shift daily following select residents who are 2 person transfers to ensure compliance by our CNA staff.
3. Audits with negative findings will have onsite corrective actions including onsite education with the CNA and involved Nurse.
4. Audits with negative findings will be reviewed by the DNS for follow up corrections as needed.

B 1. The DNS in conjunction with the Consultant has developed an audit tool to interview Nurses and CNAs to validate awareness of their assignment and ADL needs of the residents.

2. Audits will be done by the RN supervisors targeting any new CNAs or float CNAS, on each unit Q shift over the next Quarter.
3. Audits with negative findings will have immediate onsite corrective actions and review by the DNS for awareness and follow up as indicated.
4. All audit findings will be discussed at the Morning Meeting M-F to ensure awareness and follow up by the RN Supervisors as needed. Ongoing.
5. All Audit findings will be presented to the QA Committee monthly x 3 , then quarterly thereafter for ongoing compliance.
Completed 3/22/18.
Responsible Discipline: DNS

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 23, 2018
Corrected date: March 29, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and family interview and record review the facility did not take actions to prevent further potential abuse after a resident alleged a staff member abused them. Specifically, Resident #148 made an allegation against a LPN(Licensed Practical Nurse). The facility did not remove the LPN from providing care to the resident during the investigation into the allegations. This was evident for 1 out of 2 residents reviewed for abuse out of a sample of 35 residents. (Resident #148) Complaint # NY 819 The findings are: On 1/17/18 at approximately 10:00 AM the resident was observed in the room with family member and friend in wheelchair. resident observed well groom and the surveyor said hello to resident in Cantonese. Resident family member stated that everything is good and had no concerns. Another Observation on 1/18/18 at 3 PM and again on 1/19/17 at 4 PM resident was laying in bed. Resident # 148 daughter in law was in room and stated, that everything is good and the facility is thumbs up. Resident # 148 is a [AGE] year old who has severe cognitive dementia with no behaviors noted. Resident is totally dependant of two for bed mobility and transfer and toilet use. Resident is dependant of one for eating, personal hygiene and locomotion on and off unit. Resident has impairment on both sides of lower extremity. Active Diagnosis: [REDACTED]. Resident receiving an antidepressant. Review of A/I documents, On 9/21/17 she reported to the family that sometime after 11:00 PM on 9/201/7 a staff member roused her from her sleep by grabbing her in the abdominal area without warning. The resident stated said she felt intense pain from the rough handling and tried to ward off the staff members hands. In response, the staff member slapped her face repeatedly with a pillow and pinched her left upper arm. Nursing note on 9/22/17 at 2:37 am documents, 9/21/17 late note resident hitting charge nurse on right arm with her fist scratching her arm/ pinching attempting to slap /kick with her left foot while giving medication thru peg tube explained I am here to help you and prevent you from hurting me and protecting you at the same time spoke family previously about behavior and they laughed charge nurse made them aware the situation was not funny she stopped for awhile. Nurse note on 9/22/17 on 7:04 PM documents, Late note for 7 am to 3 PM shift. Evaluated by nurse practitioner for s/p reported incident on 9/20/17 np ordered psych evaluation for [MEDICAL CONDITION], noted agitation when attempted to check residents left arm after explaining the purpose, calm down with calm verbal communication from translator (daughter in law standing near by.) The Nurse progress note dated on 9/22/17 at 8:44 am documents, resident med given via peg tube on 11 PM to 7 am shift supervisor present with charge nurse. Resident raising hands and left leg in an attempt to strike supervisor assisted in preventing occurrence CNA assisted charge nurse in obtaining fs 188 hand held. The NP note documented on 9/22/17 documented, Asked by ADON (Assistant Director of Nursing) to see this 81 y/o female s/p (status [REDACTED].Alert, Asian female, Chinese speaking with family at bedside. Resident cooperative with exam Right hand dime sized area of ecchymosis(s/p phlebotomy as per family) , bilateral forearms with multiple areas of senile purpura. Left upper arm with approximately 3 cm x 2.5 cm area of ecchymosis. A/P s/p incident. Refer to psych for evaluation. Provide safety and emotional support for resident and family at times. Policy for Abuse Prohibition effective date on 6/11 documents 2) Employee Training: All employees/staff volunteers shall be trained on Abuse Prohibition during their orientation and annually thereafter and will acknowledge their obligation to dutifully report any suspected or actual Resident abuse by certifying their understanding of the Facility's Codes of ethics and conduct. a) The facility will not tolerate any staff member in participating in retaliatory action towards any individual who reports abuse, any reported threats of retaliation will be dealt with immediately and severely. c) additional training includes Dementia care Training and appropriate methods to handle aggressive behavior and recognition of, and methods of managing, caregiver stress. Interview with the DNS on 1/19/18 at approximately 2:30 PM with the SA surveyor. Review of the inservices the LPN received documents that the last inserviced on (MONTH) 25, (YEAR) was for Residents Rights/Abuse/wandering/Elopement. The SA asked the DNS what is the policy and procedure for the LPN to be inserviced on Abuse. The DNS stated it should be yearly and as needed. Care Plan dated on 9/22/17 and revised on 1/18/18 potential to be abused: Goal: Resident will have no indications of psychosocial well being problem by review date. Resident # 148 will effectively cope with her feelings isolation, unhappiness, anger by the review date. Interventions: Allow Resident # 148 time to answer questions and to verbalize feelings perceptions, and fears whenever she has concern. An interview with RN supervisor that worked 3PM to 11 PM was conducted on 1/22/18. The RN supervisor stated, I got a page from the RN on unit stating that a family member would like to talk to the RN supervisor. I spoke to granddaughter of the Resident. She told that her family member came by during day shift and complained to that CNA in room that was taking care of resident. The Granddaughter stated to the RN that the night before the 11pm to 7 am shift that a nurse had pinch resident #148 on her hand. The family member who complained to CNA did not speak English but the granddaughter was able to speak with RN. The RN supervisor instructed the granddaughter to write incident down and gave it to RN supervisor. She told the granddaughter that we don't tolerate such actions in the nursing home and they will investigate to the fullest. The RN supervisor stated she did and saw a small discoloration on the left upper arm. The RN supervisor stated she documented it on the investigation form. The resident seen calm and she was able to talk to her in a calm manner. When the RN supervisor asked the resident questions the granddaughter translated and she was oriented and answered questions appropriately. When she asked the granddaughter to ask the resident if the nurse prior to giving medication via peg did she explain to her what she was doing, the resident stated the nurse didn't explained to her what she was going to do and the resident stated she got agitated because she was sleeping and they pulled the sheet to give her the meds thru the tube. The resident became agitated and knocked her hand away. The resident stated she put up a fight and from the RN understanding the LPN left without her medication. The resident stated she was afraid and did not want the LPN touching her. The night supervisor got all the information and the RN supervisor told her what the granddaughter said. The RN supervisor gave her a copy of granddaughter statement and told her to follow up. She told the RN supervisor at night that she did not want the LPN to take care of her and the granddaughter said the same thing. The RN stated that when she was interviewing the resident, the resident was alert and oriented and allowed RN supervisor to check her arm. An Interview with the NP was conducted on 01/23/18 at 12:30 PM. The NP stated she was told on 9/22/17 by the ADON (Assistant Director of Nursing) about the family complaint. The NP read that LPN was rough with the resident and the ADON wanted the NP to assess the resident. The NP did a physical assessment from head to toe. The resident was cooperative with NP and had a family member with her. The NP observed on right hand dime size ecchymotic area and family said blood It was an area that the phlebotomist would do. The resident pulled up her sleeve and the NP noted an ecchymotic area 3 x 2.5 cm on the Left arm which could be indicative of someone pinching it, laying on it, banging it. There can be a lot of cause factors. There was senile purpura on bilateral forearms. The NP continued to state she did not observe anything on stomach, back or legs. On 1/23/18 at 4:30 PM the Administrator was interviewed. It was reported on 9/22/17 and the administrator was made aware of it and call it in to DOH. It was discussed on 9/22/17 and they decided to call in the incident to DOH. The RN at night assumed that she was protecting the resident by stating to the LPN that she should not go in resident's room by herself. The RN spoke to the resident in her language and reassured the resident she would be in the room when the LPN was giving treatment. The administrator stated that the resident was calm but the RN should have sent her home. The administrator continued by stating the RN supervisor did not realize she could have sent the LPN home. She thought she was protecting the resident by not allowing the LPN in the resident's room alone. They were through involved and usually signs off on investigation. On 01/23/18 at 05:00 PM the education staff manger was interviewed. She stated that as the education staff manager she sends out monthly calendar and schedule evenings and night and gives a gentle reminder. Go thru all different type of abuse, if they see resident being abuse, first thing separate, protect make sure that staff member is not by the resident and report what you saw and what you did, report to supervisor. A listing of all nursing staff members to come down at the end of the month and let charge nurse know who is missing. The surveyor asked how does he ensure that the LPN had her mandatory in the past year. The administrator stated that they would ensure anytime in (YEAR) that this LPN would get reinserviced on abuse in the year. Do education for all staff that the ADON would have educated the RN supervisors on Abuse prohibition. Interview with the DON was conducted on 01/23/18 at 05:16 PM. The DON concluded from the investigation based on seeing the resident on Monday [DATE], (YEAR). The DON saw on left arm brownish discoloration. There was no pain. Resident was calm not aware of any behaviors. Resident statement was consistent and was not there and she told it to staff and family and consistent with info that it is plausible that the discoloration is from the LPN pinching resident. The LPN never had or nothing in her file that would indicate she would have a propensity to abuse, mistreat or neglect a resident. Clearly if she did there would be information in her file. When there is any allegation of abuse they would immediately separate the parties, the employee would be suspended pending investigation immediately. The DON continued to state it has always been our policy once an allegation brought to light an employee should be suspended. The DON stated that the RN supervisor felt she was protecting the resident by not allowing the LPN to enter the resident's room unsupervised. The DON continued to state that RN supervisor did not know she was allowed to send the LPN home. After this incident all RN supervisor was reinserviced. The DON responded by the time the facility was discussing it the LPN resigned. 415.4

Plan of Correction: ApprovedFebruary 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: Immediate Corrections by ADON upon notification.
As per the facility policy, the DON and ADON conducted a complete and thorough investigation into the complaint of this resident to her family member that on the night of 9/20/2017, after 11pm, she was physically abused by an African American woman dressed in white wearing a small black hat covering dark hair in small braids/dreads and in her 50s or 60s. Resident told her family member that she was roughly aroused from her sleep by grabbing at her abdomen area without warning. When the resident tried to ward off the caretaker?s hands, she was slapped in the face repeatedly with a pillow, and pinched on her left arm.
Upon notification, the ADON immediately initiated a thorough investigation, and suspended the employee identified in this incident. Completed 9/22/2017.
1. The staff provided emotional support for the resident and family per documentation. Ongoing.
2. RN Supervisors re-educated by the DON/ADON on the policy and procedure on Abuse, Neglect, and Mistreatment of [REDACTED]. Completed 9/22 /2017.
3. The resident was evaluated by the Nurse Practitioner and a detailed note was entered into the EHR with her assessment findings. Completed 9/22/2017
4. The NP ordered a Psychiatric evaluation. Ordered 9/22/2017, and Completed 9/27/2017.
5. The ADON notified the DOH as per requirement on 9/22/2017.
Element #2: Actions by the Facility to protect other residents in similar situations:
If an allegation of resident abuse is made the following actions will occur:
1. ?The alleged employee will be removed from the resident care area immediately and escorted out of the facility.
?Employee will be suspended pending the outcome of the investigation.
?The investigation will include, but not limited to, the following:
1) A physician or Nurse Practitioner will perform a physical examination of t resident and order treatment, if necessary.
2) DON/designee and Social Worker will interview resident if possible and or designated representative
3) DON/designee will interview other residents on the unit.
4) DON/designee will interview other employees present at time of alleged abuse.
?At the conclusion of the investigation the employment status of the suspended employee will be determined and appropriate interventions taken.

2. RN Supervisors reeducated the staff related to the policy and procedure on Abuse, Neglect, and Mistreatment of [REDACTED].
3. Social worker will interview all of the residents/designated representatives on the unit where this occurred, to ensure that no other residents were harmed. There were no other cases per the Social Worker. Completed 2/16/2018.
4. The Social Worker will ensure that the CCPs for all residents on the unit where the event occurred are reviewed/revised to reflect where there is a Potential for Abuse. There were no other residents identified with complaints of Abuse on the unit where the event occurred. Completed 2/16/2018.

Element #3: Measures the facility will take/Systems the facility will alter to ensure that the problem does not recur.
1. The DON/Designee will review the policy and procedure on Abuse, Neglect and Mistreatment of [REDACTED]. This was done and found to be compliant with regulatory requirements. Completed 2/16/2018.
2. All employees were re-educated to the policy & procedure related to abuse, neglect, mistreatment and misappropriation and that the facility has zero tolerance for any of the above allegations.
3. Any employee who is aware of any violation to the above policy and does not report it will be suspended pending investigation in the same manner as the alleged abuser.
4. The DON has reviewed the policy on Accidents/Incidents, and found it to be in compliance with regulatory requirements. Completed 2/16/2018
5. The Education Manager will continue to conduct annual in-services on Abuse to all staffs which will now include a Competency Evaluation related to the policy. All newly hired employees will receive this in-service. The Attendance and Lesson Plan will be kept for validation of the in-services. Ongoing.
6. The Education Manager/Designee will maintain records of attendance to ensure that all staffs attend on a timely manner. Ongoing.

Element #4: How will the facility monitor its performance to ensure that solutions are sustained?
1. The DON/Designee will develop an Audit Tool related to timely completion of Accidents and Incidents Forms to ensure that the documentation on these forms is complete and accurate, and if potential for abuse is identified, then an investigation is initiated immediately. Date of Completion 3/22/2018.
2. RN Supervisors will conduct a QA Audit of 10% of all Accidents/Incidents reports. Completed 3/22/2018.
3. The DON/designee will conduct monthly audits and report to the QA Committee, until 100% compliance is obtained. Frequency of the Audits will be re-evaluated at that time. Ongoing.

Standard Life Safety Code Citations

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: January 23, 2018
Corrected date: March 23, 2018

Citation Details

Based on staff interview and documentation review, the facility failed to develop and implement emergency preparedness policies and procedures, based on the risk assessment. The finding is: On 1/17/18 and 1/18/18 between the hours of 8am and 3pm during the recertification survey, the following was observed: Review of the facility's Emergency Preparedness manual revealed no policies or procedures had been developed or implemented based on the risk assessment. The facility had policies and procedures for emergencies, but it was not specific regarding the facility and community based risk assessment utilizing the all- hazards approach. In an interview on 1/18/2018 at approximately 9:15am with the Assistant Administrator, she stated she has recently taken over the position and is in the process of updating the Emergency Manual. 483.73(b)

Plan of Correction: ApprovedMarch 2, 2018

Element #1
On 1/17/2018 and 1/18/2018 during review of the Emergency Preparedness Plan it was determined that no policies or procedures had been developed on implemented based on the risk assessment for emergencies. Complete Date: 1/18/2018

Element #2
? The Hazard Vulnerability Assessment (HVA) tool by Kaiser Permanente will be used to complete am all hazard risk assessment. The tool is designed to score potential emergencies, from very likely to happen, down to not very likely taking into consideration the likely hood the event to occur, the known risk, historical data and Manufacturer/vendor statistics and prepare a plan for each that is likely to happen down to somewhat likely to happen in our location.
? Facility Hazard Vulnerability Assessment (HVA) will assist us in our planning efforts as it assigns risks and explores our facility capabilities. Risk Assessment and Planning with an all hazards approach (natural and man-made) will be completed focusing on capacities and capabilities addressing our facility?s population with unique needs of residents including number of beds, level of care, availability of staff and supplies available during an emergency. The HVA will be reviewed at least annually.
? Community based risk assessments utilized for our facility HVA in conjunction with our Facility Risk Assessment include New York City Hazard Mitigation Plan 2014 with Annex updates (YEAR)-2017, New York State Department of Public health Influenza Surveillance Report, FEMA National Incident Management System (MONTH) (YEAR), FEMA Developing and Maintaining United States Homeland Security Threat and Hazard Identification and Risk Assessment Guide(CPG) 201 as well as guidance from Agency for healthcare Research and Quality (AHRQ), CMS, CDC and other relevant supportive data sources.
? Our HVA will consider the type of services our facility has the ability to provide in an emergency; also continuity of operations, including delegations of authority. Include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of your facility?s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.
? Based on Facility Hazard Vulnerability Assessment (HVA), the facility will develop Policy and Procedures based on identified risk factors.
Complete Date: 3/23/2018

Element #3
? The Emergency Preparedness team will develop and implement policies and procedures as assessed based on the emergency plan set forth from our risk assessment, and the communication plan.
? Meeting with all appropriate representatives from the facility and representative from NYC Long Term Care Management Emergency preparedness Program took place on (MONTH) 8th, (YEAR).
? Facility will implement the facility Policy and Procedures based on findings of the HVA and update the Facility Emergency Preparedness Manual.
? The Emergency Preparedness policies and procedures in our emergency plan address safe evacuation from the site, staff responsibilities, and needs of our residents, staff, and volunteers who remain in the facility, subsistence needs (food, water, meds), waste disposal, alternate energy sources, preserving medical records, sharing of medical documentation, use of volunteers, evacuation plans, and a system to track locations of on-duty staff and sheltered residents.
? The policies and procedures will be reviewed and revised as necessary and updated at least annually.
? The Emergency Preparedness Team/Designee will inform about updates to the Facility Emergency Plan to residents and designated representatives at least annually.
? The Education Manager will in-service staff to the updated Emergency Preparedness Plan in (MONTH) (YEAR).The in-service will be conducted at least annually and as part of new hire orientation.
Complete Date: 3/23/2018

Element #4
? Assistant Administrator /Designee will chair a monthly Emergency Preparedness Team committee meeting inclusive to update as needed and evaluate our Emergency Preparedness plan and share information with Quality Assurance meetings.
Complete Date: 3/23/2018
? The Assistant administrator as a participant in the facility quarterly Quality Assurance meeting or as needed, will report updates to the Emergency Preparedness Plan to standing members of the committee scheduled for May, (YEAR).
? A Quality Assurance tool will be developed and implemented to ensure that the Emergency Preparedness components are updated at least annually in compliance with regulation.
Complete Date: 3/23/2018

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: January 23, 2018
Corrected date: March 23, 2018

Citation Details

Based on observation, staff interview and record review, it was determined that the facillity did not ensure that all patient care-related electrical equipment was on the preventive maintenance schedule in accordance with NFPA 99. This was observed on all units. The Findings are: On (MONTH) 17, (YEAR) and (MONTH) 18, (YEAR), between the hours of 09:30 am to 2:00 pm during the recertification survey, the facility did not ensure that patient care-related electrical equipment was checked periodically as evidenced by the absence of inspection stickers and/or an inspection log book. In an interview at approximately 11:00 am on (MONTH) 17, (YEAR), the Director of Engineering stated that the facility is currently in the process of ensuring that all resident care related equipment is on a preventive schedule. 2012 NFPA 99: 10.5.2.1.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 2, 2018

Element #1 ? Upon notification of these findings the Director of Engineering began investigating the code requirement of NFPA 101 Electrical Equipment Testing and Maintenance. Completion 1/26/18
Element #2 ? The Director of Engineering reviewed the NFPA-99 -2012 Edition (Chapter 10) and determined which Patient Care-Related
equipment needed to have the Electrical Safety Inspection performed and the Testing Interval for Inspection. Completion 2/9/18
Element #3 ?
?Director of Engineering and his designee performed a Full building evaluation and documented equipment specifications to be inputted into a Log Book maintained in the Director of Engineering office. Director of Engineering also investigated the proper equipment needed to perform the inspections and ordered the meter equipment needed. The inspections will be initiated on receipt of equipment needed and conducted as per regulations. Each piece of inspected patient care-related equipment will be labeled with inspectors name and date of audit. Completion 2/23/18
?The Director of Engineering will develop a Policy and Procedure for the type of tests and intervals of testing Patient care-related equipment. In-service education will be given to all day shift engineering personnel. Completion Date 3/9/18
Element #4 ? A QA audit tool will be developed to ensure Inspections are performed as per requirements. This audit will be completed by the Director of Engineering/Designee on 10% of identified patient care-related equipment every month and reported to the QA/QAPI Committee until 100% compliance is achieved. Frequency of reporting to the QA/QAPI Committee will be re-evaluated at that time.
Completion Date 3/23/18

NAMES AND CONTACT INFORMATION

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

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 23, 2018
Corrected date: March 23, 2018

Citation Details

Based on documentation and staff interview, the facility failed to ensure that the communication plan developed, included the name and contact information of staff, resident physician's and volunteers. The finding is: On 1/17/2018 and 1/18/2018 between the hours of 8am and 3pm during the recertification survey, the following was noted: Review of the facility's Emergency Preparedness manual revealed the development of the communication plan did not include the names and contact information of staff, resident physician's and volunteers. In an interview on 1/18/2018 with the Assistant Administrator, she stated she is working on updating the Emergency Manual and COOP (Continuity of Care) with New York City Department of Health, Incident Management Solutions program. 483.73(c)(1)

Plan of Correction: ApprovedMarch 2, 2018

Element #1
On 1/17/2018 and 1/18/2018 it was identified that the facility?s emergency manual did not include the names and contacts information of staff, resident physician?s and volunteers.
Element #2
? The contact information of staff, resident physician?s and volunteers in the communication plan of the facility Emergency Plan Manual was updated.
? An updated paper hard copy for staff contact information was printed and placed in the communication plan of the facility Emergency Preparedness Manual.
Complete Date: 1/20/2018
? Our emergency preparedness communication plan in accordance with Federal, State, and local laws will be reviewed and updated at least annually and was last updated on 2/29/2018.
Complete Date: 2/29/2018
Element #3
? The Director of Human Resources/Designee will generate a quarterly list of new staff contact information changes and forward to Assistant Administrator/Designee.
? The Assistant Administrator/Designee will update the Emergency Plan with staff,resident physician's and volunteer contact information as well as other contact information required under the regulation in the Emergency Preparedness plan at least annually.
Complete Date: 3/23/2018
Element #4
? The Assistant administrator as a participant in the facility quarterly Quality Assurance meeting or as needed, will report updates to the Emergency Preparedness Plan to standing members of the committee scheduled for May, (YEAR).
? A Quality Assurance tool will be developed and implemented to ensure that the Emergency Preparedness components are updated at least annually in compliance with regulation.
Complete Date: 3/23/2018

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: January 23, 2018
Corrected date: March 23, 2018

Citation Details

Based on staff interview and documentation review, the facility failed to conduct a documented, facility based and community based risk assessment. This occurred while reviewing the Emergency Preparedness manual for the facility. The finding is: On 1/17/18 and 1/18/18 between the hours of 8am and 3pm during the recertification survey, the following was observed: Review of the facility's Emergency Preparedness manual revealed no risk assessment had been conducted by facility. In an interview on 1/18/2018 at approximately 9:15am with the Assistant Administrator, she stated the facility is in the process of updating the Emergency Preparedness manual, but has not conducted a risk assessment. 483.73(a)(1)(2)

Plan of Correction: ApprovedMarch 2, 2018

Element #1
On 1/18/2018 on interview with the Assistant Administrator it was determined that a Facility Based and Community Based Community Assessment had not been completed. Complete Date: 1/18/2018

Element #2
?The facility emergency manual will be updated to include a facility based and community based risk assessment using an ?all hazard? approach specific to our facility geographic location.
?The Hazard Vulnerability Assessment (HVA) tool by Kaiser Permanente was selected to be used to complete an all hazard risk assessment. The tool is designed to score potential emergencies, from very likely to happen, down to not very likely taking into consideration the likely hood the event to occur, the known risk, historical data and Manufacturer/vendor statistics and prepare a plan for each that is likely to happen down to somewhat likely to happen in our location.
?Facility Hazard Vulnerability Assessment (HVA) will assist us in our planning efforts as it assigns risks and explores our facility capabilities. Risk Assessment and Planning with an all hazards approach (natural and man-made) will be completed focusing on capacities and capabilities addressing our facility?s population with unique needs of residents including number of beds, level of care, availability of staff and supplies available during an emergency. The HVA will be reviewed at least annually.
?Community based risk assessments used for our facility HVA, in conjunction with our Facility Risk Assessment, include New York City Hazard Mitigation Plan 2014 with Annex updates (YEAR)-2017, New York State Department of Public health Influenza Surveillance Report, FEMA National Incident Management System (MONTH) (YEAR), FEMA Developing and Maintaining United States Homeland Security Threat and Hazard Identification and Risk Assessment Guide(CPG) 201 as well as guidance from Agency for healthcare Research and Quality (AHRQ), CMS, CDC and other relevant supportive data sources.
?Our HVA will consider the type of services our facility has the ability to provide in an emergency; also continuity of operations, including delegations of authority as well as, a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' in our efforts to maintain an integrated response during a disaster or emergency situation, including documentation of our facility?s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.
?The facility will develop Policy and Procedures based on identified risk factors from facility Hazard Vulnerability Assessment (HVA).Complete Date: 3/23/2018
Element #3
?The Emergency Preparedness Team including Administration, Assistant Medical Director, Nursing Designee, Director of Engineering, Director of Informational Services, and Director of Environmental Services will implement the Hazard Vulnerability Assessment Tool by Kaiser Permanente. The Emergency Preparedness team will develop and implement policies and procedures based on the emergency plan set forth from our risk assessment, and the communication plan.
?Meeting with all appropriate representatives from the facility and representative from NYC Long Term Care Management Emergency preparedness Program took place on (MONTH) 8th, (YEAR).
?The facility will implement the facility Policy and Procedures based on findings of HVA and update the facility emergency Preparedness Manual at least annually.
?Facility Communication Plan will be updated at least annually to reflect risk assessment by HVA.
?The Emergency Preparedness Team/Designee will inform about updates to the Facility Emergency Plan to residents and designated representatives at least annually as per regulations.
?The Education Manager will in-service staff on facility Emergency Preparedness Plan in (MONTH) (YEAR). The in-services will be conducted at least annually and as part of new hire orientation.
Complete Date: 3/23/2018
Element #4
?Assistant Administrator /Designee will chair a monthly Emergency Preparedness Team committee meeting to update as needed and evaluate our Emergency Preparedness plan and share information with Quality Assurance meetings.
Complete Date: 3/23/2018
?The Assistant administrator as a participant in the facility quarterly Quality Assurance meeting or as needed, will report updates to the Emergency Preparedness Plan to standing members of the committee scheduled for May, (YEAR).
?A Quality Assurance tool will be developed and implemented to ensure that the Emergency Preparedness components are updated at least annually in compliance with regulation.
Complete Date: 3/23/2018

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 23, 2018
Corrected date: March 23, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that the facility had established the role of the long term care facility under an 1135 waiver. Specifically, for the provision of care, if evacuating to an alternate care site. The finding is: On 1/17/2018 and 1/18/2018 between the hours of 8am and 3pm during the recertification survey, the following was noted: Upon review of the facility's Emergency Preparedness documentation, it was revealed that the facility did not have a policy or procedures for the provision of care under an 1135 waiver. Specifically, if the facility needed to evacuate to alternate care site, no development for the provision of care while under the 1135 waiver had been prepared. In an interview on 1/18/2018 with the Assistant Administrator at approximately 11am, she stated she is new to the position and will ask her predecessor if there is a policy. In an interview on 1/18/2018 with the Administrator at approximately 2pm she stated she thinks the facility would evacuate to the school across the street. At the time of the exit, no policy addressing evacuation procedures under and 1135 waiver had been submitted for review. 483.73(b)(8)

Plan of Correction: ApprovedMarch 2, 2018

Element #1
On 1/17/2018 and 1/18/2018 it was identified that the facility?s emergency manual did not include policy or procedures for the provision of care under an 1135 waiver, specifically if the facility needed to evacuate to alternative care site.
Complete Date: 1/18/2018

Element #2
? Emergency Preparedness Team updated possible alternate care site locations in close proximity to facility location for further evaluation. Complete Date: 1/20/2018
? A meeting was held to discuss Emergency Preparedness Plan including the selection and planning for alternate care sites with all appropriate representatives from the facility and representative from NYC Long Term Care Management Emergency preparedness Program took place on (MONTH) 8th, (YEAR).
Complete Date: 2/8/2018
Element #3
? The Emergency Preparedness Team will review, update and plan for Alternate Care Site(s) at least annually.
? Within an Alternate Care Site, a modified Incident Command System structure will need to be established to accomplish resident care objectives within the Alternate Care Site and connect to the Unified Command System to obtain resources as needed.
? Facility will coordinate with local government, healthcare providers and payers will be essential to maintain resident safety, business continuity and sustain operations.
? Facility will evaluate the process for an alternate care site and will include capacity, types of existing communications, parking and loading ramps, heating, air conditioning, water and plumbing systems, kitchen facilities, areas for hand-washing stations and other safe hygiene techniques, areas for supplies and storage, wheelchair / gurney access, fire protection safety and equipment, refrigeration/cold storage for medical supplies and food , secured entrances and exits will be considered in the selection process.
? The Alternate Care Site should be accessible to at least two roadways. This would provide continued access to the Alternate Care Site in the event that one roadway becomes blocked or inaccessible.
? The Emergency Preparedness Team will review and update plans to quickly identify sources for the acquisition of medical professionals and support staff to provide services at an Alternate Care Site and consider staffing needs for site set-up, site administration, clinical and allied health functions, support functions, and operations of the site command system including needed supplies and equipment.
? Facility will review and revise as appropriate our identification and tracking system for all residents utilizing e-finds.
? Facility policies and procedures will include how to proceed if the need to provide care at an approved alternate care site arises as well as processes on any reporting required if conducting business under an approved 1135 Waiver.
? Facility policies and procedures will specifically address the facility?s role in emergencies where the President declares a major disaster or emergency under the Stafford Act or an emergency under the National Emergencies Act, and the HHS Secretary declares a public health emergency.
? Facility policies and procedures will address what coordination efforts are required during a declared emergency in which an 1135 waiver is granted.
? Facility will also develop policies and procedures to address scenarios in which a disaster declaration is not made and an 1135 waiver may not be applicable, such as during an incident affecting just the facility itself.
? Facility Policy and Procedures will include but not limited to the following resident Mobilization, Safety Requirements, Staff roles, Community Volunteer roles, Supplies, Food, system for tracking and identification of residents, Communication plan, Tagging, supply and storage of medications, staff assignment and tracking to alternative care site(s), system for documentation and HIPPA rules under the waiver.
Complete Date: 3/23/2018
Element #4
? Assistant Administrator /Designee will chair a monthly Emergency Preparedness Team committee meeting inclusive to update as needed and evaluate our Emergency Preparedness plan and share information with Quality Assurance meetings.
Complete Date: 3/23/2018
? The Assistant administrator as a participant in the facility quarterly Quality Assurance meeting or as needed, will report updates to the Emergency Preparedness Plan to standing members of the committee scheduled for May, (YEAR).
? A Quality Assurance tool will be developed and implemented to ensure that the Emergency Preparedness components are updated at least annually in compliance with regulation.
Complete Date: 3/23/2018