Henry J. Carter Skilled Nursing Facility
August 25, 2017 Certification Survey

Standard Health Citations

FF10 483.10(f)(10)(i)-(iv):FACILITY MANAGEMENT OF PERSONAL FUNDS

REGULATION: (f)(10)(i) ?If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section. (f)(10)(ii) Deposit of Funds. (A) In general: Except as set out in paragraph (f)(l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund. (B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund. (f)(10)(iii) Accounting and records. (A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident?s personal funds entrusted to the facility on the resident?s behalf. (B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (C)The individual financial record must be available to the resident through quarterly statements and upon request. (f)(10)(iv) Notice of certain balances. The facility must notify each resident that receives Medicaid benefits- (A) When the amount in the resident?s account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and (B) That, if the amount in the account, in addition to the value of the resident?s other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 25, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and interviews conducted during the recertification survey, the facility did not ensure that quarterly statements residents' personal funds were provided to the desginated representatives of non-interviewable residents. This was evident for 1 of 3 residents reviewed for Personal Funds (Resident #33). This is evidenced by the following: The facility policy and procedure for Securing Resident's Valuables and Clothing dated 4/1/13 documented the procedures for the resident accounts. The policy does not include procedures for the dissemination of quarterly statements. Resident #33 has several [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. On 8/22/17 at 2:42PM, during Stage 1, the designated representative was interviewed and stated that they do not receive quarterly statements for the resident's personal account. There was no documented evidence that the resident's designated representative was sent a quarterly statement for the resident's personal funds. On 8/23/17 at 2:09PM, the Patient Property Assistant Coordinator (PPAC) was interviewed and stated that if the resident is non-alert, the facility does not send out the statements. The PPAC further stated that she did not know how the representatives get the balances, but the alert residents come to see her to inquire about their accounts and obtain funds. On 8/24/17 at 10:58AM, the Assistant Director (AD) was interviewed in the presence of the Controller and stated The statements for alert residents are given to the residents via intraoffice as it will go to the mailroom and will be delivered to that resident on the unit. There is no documented evidence that the resident received the quarterly statements as the social workers are not involved in this process. They further stated that the process for the non-alert residents is we do not send out the statements but the statements are kept on file. If the family representative wishes they can request the quarterly statements. 10 NYCRR 415.26(h)(5)

Plan of Correction: ApprovedSeptember 15, 2017

F159
483.10(f)(10)(i)-(iv)
FACILITY MANAGEMENT OF PERSONAL FUNDS
1) Activities taken in order to achieve correction for those residents found to have been affected by the deficient practice.
Upon being informed that (non-interviewable) Resident #33?s designated representative was not provided a quarterly statement of the resident?s personal funds, we have pulled the statements provided via diskette from our Financial Institution and have mailed the statement certified return receipt to the Community next of kin.

2) Other residents identified as having the potential to be affected by the same deficient practice.
A list of all other non-interviewable residents was generated by the Director of Psychiatry and provided to the Patient Property Assistant Coordinator who in turn generated 2Q2017 quarterly statements and mailed them to the residents? representative/designee listed in the medical record.
For non-interviewable residents who do not have a representative listed in the medical record, the bank statements will be sent to the Social Work Department.
3) Measures put into place or systematic changes to ensure the same deficient practice will not recur.
The Chief Finance Officer / or their designee(s) reviewed the facility policy and procedure for ?Securing Resident?s Valuables and Clothing? and revised it to include standard work for providing a quarterly statement of a resident?s personal funds as it pertains to non-interviewable residents. Finance, Social Work, and the Patient Relations staff were in-serviced on the revised policy.
An audit tool was developed by the Chief Finance Officer / or their designee(s) to facilitate the monitoring of staff adherence to the revised policy.
4) How corrective actions will be monitored to ensure the practice will not recur.
The Chief Finance Officer / or their designee(s) will conduct monthly audits with an emphasis of staff providing a quarterly statement of a resident?s personal funds for non-interviewable residents. The observations will be documented on an audit tool. Observed deviations from the standard work will be immediately addressed by re-inservicing the appropriate staff.
Data from the observations will be used to track and trend staff compliance with the plan of correction, evaluate the plan?s effectiveness and modify the corrective actions if needed. Audit findings will be reported monthly to the Associate Director of Quality Management/Regulatory Affairs for three consecutive months or until compliance has been sustained for three consecutive months (and subsequently shared at the quarterly facility-wide Executive Quality Assurance Committee)
Person Responsible: Chief Finance Officer / or their designee(s)
Completion Date: (MONTH) 14, (YEAR)

Standard Life Safety Code Citations

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 25, 2017
Corrected date: October 27, 2017

Citation Details

2010 NFPA 13: 6.2.9.1* A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. 2010 NFPA 13: 6.2.9.2 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. 2010 NFPA 13: 8.15.3.2.1 In noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. 2010 NFPA 13: 8.15.3.2.2 Where noncombustible stair shafts are divided by walls or doors, sprinklers shall be provided on each side of the separation. Based on observation and staff interview, the facility failed to ensure that a stock of spare sprinklers was kept on the property and that sprinklers were installed in accordance with NFPA 13, 2010 edition. This was observed in the fire pump room and exit stair E within the facility. The finding is: On 8/21/2017 between the hours of 10am and 3pm during the recertification survey, the following was observed: In the fire pump room in the basement of the facility, a red box containing spare sprinkler heads was observed. The box lacked spare side wall and dry sprinklers that were observed in use within the facility. In exit stair E on the first floor, sprinkler coverage was noted to be lacking on the stair side of the door going down to the cellar. In an interview on 8/21/2017 at approximately 2:10pm with the Director of Engineering, he stated the facility is aware that they need a few types of spare sprinklers and recently purchased spare sprinkler heads. At the time of the exit, no documentation was provided verifying the sprinklers were purchased. In an interview on 8/21/2017 at approximately 2:20pm with the Director of Engineering, he stated he will address the issue with the sprinklers in the stairwell. 2012 NFPA101 2010 NFPA13 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedSeptember 22, 2017

K 351
SS=D
NFPA 10 SPRINKLER SYSTEM INSTALLATION
Upon identification of this issue, the Director of Engineering and Maintenance initiated the New York City government procurement process for the purchase of the replacement sprinkler heads and installation of the sprinkler upgrade in exit stair E. In accordance with the procurement process, we have obtained two vendor quotes that were processed as purchase orders (PO# US 8 & PO# US 4).
Interim life safety measures implemented include Hospital Police conducting safety rounds on each tour of duty in exit stir E until the sprinkler upgrade is installed.
The Director of Engineering and Maintenance inspected all of the facility?s stair towers to ensure that they met the standards and design criteria identified for sprinkling requirements. Except for exit stair E, compliance with the sprinkling requirements was found.
The Director of Engineering and Maintenance revised the monthly sprinkler preventative maintenance process to include a review/count of spare sprinkler heads to ensure an adequate/appropriate par stock. Any deviations from the established minimum stock levels will trigger an automatic replacement order.
Additionally, a Space Committee has been established and will meet on an as-needed basis to conduct a risk assessment and to develop/implement/monitor action steps (if needed) to address room changes, changes in the functions of rooms, modifications to the physical environment, etc. Recommendations of the Space Committee (which is to be chaired by the Associate Director, Facility Services) will be reported to the facility-wide Environment of Care Committee.
Person Responsible: Associate Director, Facility Services
Completion Date: (MONTH) 21, (YEAR)