Aurelia Osborn Fox Memorial Hospital
September 29, 2016 Certification Survey

Standard Health Citations

FF09 483.70(c)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: The facility must maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 21, 2016

Citation Details

Based on observation and interview during a recertification survey, the facility did not ensure that personal care equipment was maintained in safe working order for 2 of 3 units. Specifically: For Unit 3, the Sara 2000 stand lift (a device to aid in transferring residents) was observed to have a cracked base with jagged edges. Also, the plastic covering over the base was curled up on all 4 edges. For Unit 2, the gray plastic material covering the bases on two Sara lifts was curled away from the base of the lifts. There is a potential risk for injury to residents' feet from the jagged edges of the Sara lift's cracked bases and from the sharp edges of the curled up plastic covering the bases. Additionally, one Sara lift's support bar (that the residents stand on) was observed to be broken. This is evidenced by: Finding #1: Unit #3 During the initial tour and observation on 9/26/16 at 9:55 am on Unit 3, the mechanical stand lift (Sara lift 2000) was in the hallway of the unit outside a residents room with the sling used for the lift connected to the arms. The Sara lift had a broken base, with a visible jagged edge. The material covering the foot rest was curled and loose from the base and the support bar that the residents stand on was observed to be broken. During observation on 9/27/16 at 11:30 am, the mechanical stand lift (Sara lift 2000) was observed in the activity room. It had a broken base with a visible jagged edge. The gray plastic material covering the foot rest was noted to be curled and coming loose from the base and the support bar that the residents stand on was observed to be broken. The sling used with the Sara was over the top of the lift. During observation on 9/28/16 at 1:30 am on Unit 3, the mechanical stand lift (Sara lift 2000) was observed in the hallway outside a residents room with the sling used with the lift attached to the lift portion of the mechanical lift. It was observed to have a broken base with a visible jagged edge. The gray plastic material covering the foot rest was noted to be curled and coming loose from the base and the support bar that the residents stand on was observed to be broken. The sling used with the Sara was over the top of the lift. During observation on 9/29/16 at 11:30 am on Unit 3, the mechanical stand lift (Sara lift 2000) was observed in the shower room next to century tub. It was observed to have a broken base with a visible jagged edge. The gray plastic material covering the foot rest was noted to be curled and coming loose from the base and the support bar that the residents stand on was observed to be broken. The sling used with the Sara lift was over the top of the lift. During observation on 9/29/16 at 11:45 am on Unit 1, two (2) of the mechanical stand lifts (Sara lift 2000) were observed in the unit halls. The gray plastic material covering the foot rest was noted to be curled and coming loose from the base. During interview on 9/28/16 at 2:00 pm, the Certified Nursing Assistant (CNA) stated the mechanical stand lift (Sara lift 2000) with the curled broken base belongs to the unit and is used daily to lift residents. The CNA further stated no one had been told not to use it. She stated residents stand on the base and do not always have shoes on. She stated sometimes they have sox on. She stated she did not know if anyone had reported that the lift had been broken. During interview on 9/29/16 at 11:00 am, the Supervisor of Housekeeping stated she did not know who was suppose to clean the stand lifts but stated the maintenance department was in charge of maintaining the equipment and if any equipment was broken it should be taken out of service immediately. During interview on 9/29/16 at 11:15 am the maintenance mechanic for the facility stated the nurses need to notify the maintenance department if equipment is broken. He stated he was not aware of any log book that would demonstrate how often equipment is inspected. During interview on 9/29/16 at 11:30 am, the Licensed Practical Nurse (LPN) for Unit 3 stated that the stand lift (Sara lift 2000) found in the shower room was being used. She stated that the base was broken. The LPN further stated that someone should have put a sign on it and put a repair requisition in to maintenance so it would be removed from use and fixed. She stated that residents feet would be at risk for injury because they stand on the base during transfer and do not always have shoes on. During interview on 9/29/16 at 12:00 pm the Register Nurse Unit Manager (RNUM) for Unit 3 stated the stand lift (Sara lift 2000) had been removed today from use and that a maintenance requisition was being done for needed repair. She stated she hadn't been made aware that the base had been broken until today. She stated the LPN had told her today that the base was broken. She further stated the gray material on the foot rest of the Sera lifts had been curling away from the bases for awhile and was not sure why maintenance had not addressed the problem. She stated the CNA's wipe down the equipment when possible and that the night shift wash the pads used once a week or more if needed. The RNUM was not sure who regularly inspects the equipment but stated if there is a problem with the equipment the person who found the problem should notify her or maintenance so it can be addressed. 10 NYCRR 483.70(c)(2)

Plan of Correction: ApprovedOctober 24, 2016

The lift equipment that was damaged was taken out of service for repair.
All lifts were identified and cataloged. Each lift being utilized in the nursing home were assessed to ensure it was in good working condition.
The organization has a work order system to request repairs, and to take faulty equipment out of service. Tags are available to identify items that are out of service, and ready to be retrieved for repair.
A mandatory education will be conducted for all nursing staff to re-educate on the necessity to utilize the work order system, and to remove any lift or piece of faulty equipment out of service.
On a weekly basis all lifts will be cleaned and observed for defects. Repairs will be completed.
A QI monitor will be developed to assess and assure facility compliance with maintaining clean and proper functioning, well maintained lift equipment. The monitor will be conducted weekly on a sample of the lifts from each of the 3 nursing units.
The results of the QI monitor will be presented to the NH QA Committee and to the Board QRC Committee.
Responsibility of the Director: Plant Operations and Maintenance

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 21, 2016

Citation Details

Based on observation, record review, and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that automatic dishwashing machines are to be operated in accordance with the manufacture instructions, and chemicals used in food equipment sanitizing are to be at the correct concentration. Specifically, the automatic dish washing machine was not rinsing in accordance with the manufacturer ' s instructions, and the quaternary ammonium compound chemical sanitizing rinse (QAC) was below than that required by the manufacturer. This is evidenced as follows. The main kitchen was inspected on 09/26/2016 at 9:55 am. The automatic dish washing machine was rinsing at 185 degrees Fahrenheit and 30 pounds per square inch (psi) water flow pressure. The concentration of QAC being used to sanitize food equipment was zero (0) parts per million (ppm) when tested at 71 degrees Fahrenheit (F). The automatic dish washing machine instructions were reviewed on 09/26/2016. These instructions state that the final rinse flow pressure is to be between 15 and 25 psi. The instructions on the bottle of concentrated QAC and the QAC test papers were reviewed on 09/26/2016. The instructions on the concentrated QAC state that the concentration is to be between 150 ppm and 400 ppm, and the instructions on the test papers state that the sample temperature is to be between 65 F and 75 F. The Food Service Director stated in an interview conducted on 09/26/2016 at 10:30 am that she believes the concentration of QAC was low due to dilution from being used and she does not know why the automatic dishwashing machine was rinsing below the required water pressure. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.113

Plan of Correction: ApprovedOctober 24, 2016

The Food Service Director contacted our Dish Machine Service company. The Water Flow Pressure was adjusted to 20 psi.
The Water Pressure will be checked and documented 3 times per day. This is conducted by the Supervisor. The PSI log has been revised to identify the acceptable range for Water Pressure (15-25 psi) as a visual reminder.
All Supervisory Staff and Kitchen Staff will be educated on the reason as to the importance of a pressure between 15-25 psi, as recommended by the equipment manufacturer.
A new policy and procedure has been developed to follow if the pressure is discovered to be out of acceptable pressure range.
A QA monitor will be conducted weekly to assure that the water pressure is in acceptable range, and that appropriate documentation is being completed. This monitor will continue weekly for 3 month.
Results of the QA will be presented to the NH QA Committee and to the Board QRC Committee.
The Food Service Director identified that the battery level on the Auto-Dispensing unit for the QAC was at a low level. The Food Service Director obtained a new battery from Eco-Lab. A spare will be kept on hand.
Per Eco-Lab Specifications, a manual feed of QAC was used to ensure that levels were between 150-400 ppm.
Staff education will be conducted on the policy and procedure for manual dilution of the QAC.
A log has been developed to document that the battery on the Auto-dispensing unit is at an acceptable power level.
A QA monitor will be conducted weekly to assure that the Battery Log and the QAC Concentration levels are at an acceptable level.
The results of the QA Monitor will be presented to the NH QA Committee and to the Board QRC Committee.
Responsibility of the Food Service Director.

FF09 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 21, 2016

Citation Details

Based on observation and record review during the recertification survey, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary interior on 2 of 3 units observed. Specifically: mechanical lifts, used to transfer residents, were soiled. This is evidenced by: Finding #1: Unit 1 During initial tour of Unit 1 on 9/26/16 at 10:15 am, two mechanical stand lifts (Sera lifts) were observed with soiled bases. Also, one of the lifts had the foot plate material on the base curling up significantly on the sides with food matter under the curled edges. During observation on 9/28/16 at 9:05 am, both lifts were still in the same condition. During observation on 9/29/16 at 11:44 am, both lifts were in the same condition. Finding #2: Unit 3 During initial tour of Unit 3 on 9/26/16 at 9:55 am, two mechanical lifts, one Sera lift and one hoyer lift (a lift that is used to completely lift a resident for the purpose of transferring residents who can not stand) were observed with soiled bases. The Sera lift also had a foot plate material on the base which was curled up significantly on the sides with food mater under the edges and the base was broken. The hoyer lift next to it had a soiled base and hand rail. During observation on 9/27/16 at 11:30 am, on Unit 3 the mechanical stand lift (Sara lift 2000) was observed in the activity room next to a hoyer lift. It was observed to have a broken base with a visible jagged edge. The gray plastic material covering the foot rest was noted to be curled and coming loose from the base with dried food matter under the curled edges and the support bar that the residents stand on was observed to be broken. The sling used with the Sara lift was over the top of the lift and was soiled and wet. The Hoyer lift base was soiled with food and dust. During observation on 9/28/16 at 1:30 pm, on Unit 3 the mechanical stand lift (Sara lift 2000) was observed in the hallway outside a residents room, the sling used with the lift was soiled with a brown stain. The gray plastic material covering the foot rest was noted to be curled and coming loose from the base and had food particles under the curled areas. The base on another Sara lift and the base on the Hoyer lift were soiled with dust and dried food particles. During observation on 9/29/16 at 11:30 am, on Unit 3 the Hoyer mechanical lift and 2nd Sara lift was noted to be in the same condition as the previous days. The broken Sara lift 2000 was observed in the shower room next to the century tub. The gray plastic material covering the foot rest was noted to be curled and coming loose from the base and was soiled with food particles under the curled edges. During interview on 9/28/16 at 2:00 pm, the Certified Nursing Assistant (CNA) stated the mechanical stand lifts are cleaned by housekeeping. She stated sometimes the CNA's wipe them down if they have time but that housekeeping is responsible for cleaning the equipment. During interview on 9/29/16 at 11:00 am, the Supervisor of Housekeeping stated she did not know who was suppose to clean the mechanical lifts. She stated the CNA's should be cleaning them if they are visibly soiled. She stated housekeeping should also be checking to see that equipment is kept clean daily. She stated it is everyone's job to maintain a clean environment for the residents and this included cleaning equipment. During interview on 9/29/16 at 11:30 am, the Licensed Practical Nurse (LPN) for Unit 3 stated that the stand lift (Sara lift 2000) found in the shower room was being used. She stated she did not know who was responsible to clean the mechanical lifts but that the CNA's do clean the pads weekly. She stated the pads and slings used with the lifts should be cleaned when soiled. During an interview on 9/29/16 at 12:00 PM the Register Nurse Unit Manager (RNUM) for Unit 3 stated the mechanical lift should be cleaned by the CNA's if they are soiled during the transfer of the resident. She further stated the gray material on the foot rest had been curling away from the base for awhile and was not sure why maintenance had not addressed the problem. She stated housekeeping should make sure any dried food on the bases is cleaned daily. The RNUM further stated the CNA's wipe down the equipment when possible and that the night shift wash the lift pads once a week or more if needed. The RNUM was not sure who regularly inspects the equipment but stated if there is a problem with the equipment the person who found the problem should notify her or a supervisor so it can be addressed. 10NYCRR415.5(h)(2)

Plan of Correction: ApprovedOctober 21, 2016

During survey, the lift with the damaged footplate was taken out of service. All soiled lifts were cleaned.
All lifts were observed for cleanliness and damage.
All lifts have been permanently labeled for identification. A log has been developed to record weekly cleaning and preventive maintenance.
Nursing is assigned to complete daily cleaning of all lifts for immediate soiling issues.
Education will be provided to the maintenance and nursing staff regarding the importance of maintaining proper functioning equipment, removing damaged or faulty equipment from service, the equipment tagging and work order system, and the cleaning responsibilities and procedures for maintenance and nursing staff.
A QI monitor will be developed to assess compliance with maintaining clean and proper functioning and well maintained lift equipment.
Responsibility of the Director of Plant Operations

E3BP 402.9(b)(2):RESPONSIBILITIES OF PROVIDERS; REQUIRED NOTIF

REGULATION: Section 402.9 Responsibilities of Providers; Required Notifications. ...... (b) Notifications. A provider must immediately, but within no later than 30 calendar days after the event, notify the Department, and document such notification occurred, when: ...... (2) any employee who was subject to, and underwent, a criminal history record check in accordance with this Part is no longer employed by the provider.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: September 29, 2016
Corrected date: November 21, 2016

Citation Details

Based on record review and staff interview during a recertification survey , it was determined that the facility did not take appropriate actions after the termination of employees. Chapter 10 of the New York State Codes Rules and Regulations section 402.9 (b)(2) Responsibilities of Providers; Required Notifications requires that any employee who was subject to, and underwent, a criminal history record check (CHRC) in accordance with this Part is no longer employed by the provider, the provider must immediately, but within no later than 30 calendar days after the event, notify the New York State Department of Health (The Department), and document such notification occurred. Specifically, the facility did not notify The Department within 30 calendar days of the termination of employment of one (1) of five (5) new employees reviewed. The personnel records of five (5) new employees were reviewed on 09/28/2016. The records for Certified Nurse Aide #1 show that she was terminated on 08/04/2016 and that The Department was notified on 09/22/2016, 49 days after termination. The Human Resources Specialist stated in an interview conducted on 09/28/2016 at 9:45 am that she does not know why The Department was not notified within 30 days. 10 NYCRR 402.7(a) (2) (i)

Plan of Correction: ApprovedOctober 26, 2016

The Termination Notice for the employee termination cited during survey was submitted late. No further remedy post survey could be accomplished for this finding.
Human Resources will review the employment records of all employees terminated from our employment during the former 12 month period to confirm the CHRC Termination Notice was completed.
As a visual/procedural tool, the Human Resources/ CHRC Coordinators developed a new termination checklist. This Checklist includes recording of the completion date of the Termination Notice. Completion of all aspects of the termination process are then verified by another HR Specialist to ensure that the CHRC Termination Notice is completed within 30 days, and the receipt is filed in the employees employment record.
All managers with employees that require CHRC Background checks will be required to attend an educational session. The objective is to educate the manager on their role in assuring facility compliance in completing timely Termination Notices. The relevance of the CHRC Termination Notification process will be highlighted.
The Director of Human Resources will complete a weekly QA Monitor to ensure that all newly terminated employees have been Terminated through the CHRC System. With continued compliance for 3 consecutive months, this monitor will be completed monthly thereafter. This monitor will be reported to the NH QA Committee and then to the Board QRC Committee.
Responsibility of the Director of Human Resources

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview during the recertification survey, it was determined that the facility did not maintain the electrical system in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 1999 Edition section 3-3 requires a minimum number of electrical outlets in resident rooms. Specifically, for two (2) of eleven (11) resident rooms checked, electrical devices utilized multi adaptor outlets not individual wall outlets. Multi adaptor outlets are devices connected to wall outlets allowing for 6 rather than one electric device to be connected to the normal power supply. The provisions of the applicable categorical waiver were not met. This is evidenced as follows. A general inspection of the facility conducted on 09/29/2016 at 9:00 am. In resident rooms [ROOM NUMBERS] electronic devices (televisions) were plugged into multi-adaptor outlets. The temporary Director of Plant Operations stated in an interview conducted on 09/29/2016 at 10:00 am that the use of multi-adaptor outlets is not standard practice and that family members may have brought in the adaptors. 42 CFR 483.70 (a) (1); 1999 NFPA 99 3-3; 10 NYCRR 713-1.1, 711.2 (19)

Plan of Correction: ApprovedOctober 25, 2016

For the rooms identified during survey that were utilizing Multi Adaptor Outlets (MAO), the MAO has been removed and only the individual wall outlet is being utilized.
The Facility Staff is conducting a survey of every resident room to identify if other MAO's are being utilized. A detailed report will be developed. All MAO's will be removed.
A letter will be sent to all Resident Sponsors alerting them to the fact that MAO's are not allowed within the facility. The Administrator will address the same at Resident Council and Family Council meeting.
Admissions Staff will alert new Residents and their Sponsors that MAO's are not allowed by Code.
All Nursing and Maintenance Staff and members of the Environment of Care Team will be educated on the Regulations not allowing MAO's without waiver.
The Environmental Of Care Team QI Monitor will be revised to include a section to observe for MAO's within the rooms.
The E(NAME) Team will conduct a survey on a sampling of room to determine compliance with the regulation. This survey will be completed weekly for 3 months.With continued compliance the survey frequency will be monthly thereafter. Results of the QI Monitor will be reported to the NH QA Committee and to the Board QRC Committee.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2016
Corrected date: November 21, 2016

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the automatic sprinkler system was not installed in accordance with adopted regulations. The Centers for Medicare and Medicaid Services published a Final Ruling in the Federal Register on (MONTH) 13, 2008 (73 FR ) requiring all long term care facilities to have full automatic sprinkler protection in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition by (MONTH) 13, 2013. Specifically, automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows. An assessment of the sprinkler system was conducted on 09/27/2016 at 9:00 am. Light fixtures obstructed the automatic sprinkler spray area in the Archives Hallway; Microbiology Lab; Speech Therapy Office; Unit Three janitor closets, old chute room, communications closet, electrical room, and stretcher shower room; and Unit One large shower and main foyer. The temporary Director of Plant Operations stated in an interview on 09/27/2016 at 12:00 pm that the obstructions existed prior to being hired, but the sprinklers should have been installed according to code requirements. 42 CFR 483.70 (a) (1); 73, FR ; 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-6.5; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedOctober 25, 2016

The facility is preparing to eliminate the Sprinkler Head obstructions by installing flush mount lighting fixtures or by relocating the current lighting fixture in the rooms identified during the survey.
The Maintenance Staff are conducting a room by room survey of the entire nursing home to determine if there are any other areas of non-conformity that were not identified during survey. A detailed report will be developed and a plan made to correct any other areas of non-conformity.
The Maintenance Staff and the members of the Environmental of Care Team will be educated on the NFPA requirement. The Environmental Rounds QI form will be revised, and a statement added regarding Sprinkler Head Obstruction from ceiling fixtures.
The Director of Plant Operations and Maintenance will report QI findings and weekly Corrective Action Status to the NH QA team and the Board QRC committee.