Regal Heights Rehabilitation and Health Care Center
February 15, 2018 Certification/complaint Survey

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 22, 2018
Corrected date: April 20, 2018

Citation Details

2011 NFPA 70: 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 2011 NFPA 70: 590.2 All Wiring Installations. (A) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. (B) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation. 590.3 Time Constraints. (A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities. (B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes. (C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work. (D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. Based on observation and staff interview, extension cords were observed in use in the facility. This was noted on one of eight floors. The findings are: On 2/21/18 between 11:00am- 11:30am during the recertification survey, extensions cords were observed in use on the 1st floor. Examples are: 1) Three extension cords were noted plugged into a relocatable power tap in the Social Work office 2) An extension cord was observed in the Physical Therapy office In an interview on 2/21/18 at approximately 11:20am, the Director of Environmental Services stated that the extensions cords would be removed immediately. 2011 NFPA 70: 400.8, 590.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 8, 2018

I. IMMEDIATE CORRECTIVE ACTION
The facility maintenance staff immediately removed unapproved power strips, extension cords, and the ?daisy chaining? of power strip from the Social Work Office and Physical Therapy.
II. IDENTIFICATION OF OTHER RESIDENTS
All areas throughout facility were checked for unapproved power strips, extension cords, and ?daisy chaining? of power strips. No other areas were identified.
III. SYSTEMIC CHANGES
The Director of Environmental Services/Designee will be conducting weekly environmental rounds for three (3) months and monthly rounds thereafter.
Education to all staff will be provided by the In-service Coordinator to ensure the following are not in use:
1. Extension cords
2. Unapproved power strips
3. Power strips and/or extension cords installed in series
Any devices found during these rounds will be removed and staff will be re-educated.
IV. QUALITY ASSURANCE
The Director of Environmental Services /Designee will review weekly environmental rounds for cases of:
1. Extension cords
2. Unapproved power strips
3. Power strips and/or extension cords installed in series
The Director of Environmental Services or Designee will report the result of these audits to the QAPI Committee on a quarterly basis for evaluation and follow-up.
Responsible party: Administrator, Director of Environmental Services and Maintenance

EP TESTING REQUIREMENTS

REGULATION: *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 22, 2018
Corrected date: April 20, 2018

Citation Details

Based on documentation review and staff interview, the facility did not conduct a full-scale community-based drill. There was no documentation provided at the time of the survey. The findings are: On 2/22/18 between 9:40am- 1:00pm during the recertification survey, review of the facility's Emergency Preparedness plan revealed that they did not conduct a full-scale community-based drill. The facility did conduct an individual, facility-based drill but there was no documentation provided at the time of the survey that a full-scale community-based drill involving multiple agencies, jurisdictions and disciplines was conducted. In an interview on 2/22/18 at approximately 11:25am, the Administrator stated that an evacuation drill was conducted with their life safety consultant as an observer. He further stated that they will involve local authorities in a community-based drill.

Plan of Correction: ApprovedMarch 8, 2018

I. IMMEDIATE CORRECTIVE ACTION
No residents were identified in the Statement of Deficiencies.
Regal Heights will conduct a full-scale community-based drill involving multiple agencies, jurisdictions, and disciplines.
II. IDENTIFICATION OF OTHER RESIDENTS
All residents have been identified as potentially being affected by this practice.
III. SYSTEMIC CHANGES
The Administrator of Regal Heights will incorporate multiple agencies, jurisdictions, and disciplines in a full-scale exercise.
IV. QUALITY ASSURANCE
The Administrator will report on exercises and updates to the Emergency Preparedness to the QAPI Committee on a quarterly basis for evaluation and follow-up.
Responsible party: Administrator & Director of Environmental Services

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 22, 2018
Corrected date: April 20, 2018

Citation Details

2012 NFPA 101: 19.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8. 2012 NFPA 101: 7.8.1.2.3* Energy-saving sensors, switches, timers, or controllers shall be approved and shall not compromise the continuity of illumination of the means of egress required by 7.8.1.2. Based on observation and staff interview, the facility did not ensure that illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention in that exit discharge lighting was operable by a timer device. This was noted at exit discharge locations around the perimeter of the building. The findings are: On 2/21/18 between 11:00am- 12:00pm during the recertification survey, exit discharge lighting units around the perimeter of the building were noted to be operable by a timer device. As a result of this configuration, egress lighting would only turn on when the timer was set. There would be no illumination automatically occurring at all times because the timer is set for only a specific time. In an interview on 2/22/18 at approximately 9:35am, the Director of Environmental Services stated that she does not think the lights are on a photocell but they can be replaced. 2012 NFPA 101: 19.2.8, 7.8.1.2.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 8, 2018

I. IMMEDIATE CORRECTIVE ACTION
No residents were identified in the Statement of Deficiencies.
The Director of Environmental Service conducted a survey of all illumination of means of egress, including exit discharge lighting to determine compliance with lighting being continuously in operation or capable of automatic operation without manual intervention.
II. IDENTIFICATION OF OTHER RESIDENTS
All residents have been identified as potentially being affected by this practice.
III. SYSTEMIC CHANGES
All illumination of means of egress including exit discharge locations around perimeter of building will be replaced with photo-cell sensors.
The Director of Environmental Services will conduct monthly inspection of all above referenced illumination as part of the facilities established preventive maintenance program and record all inspections in the facilities Records & Logs.
All negative findings will be corrected immediately.
IV. QUALITY ASSURANCE
The Director of Environmental Services will report on monthly inspections of the exit lighting to the QAPI Committee on a quarterly basis for evaluation and follow-up.
Responsible party: Administrator, Director of Environmental Services and Maintenance

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: February 22, 2018
Corrected date: April 20, 2018

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address the role of the facility under a waiver declared by the Secretary. The facility lacked a policy. The findings are: On 2/22/18 between 9:40am- 1:00pm during the recertification survey, review of the facility's Emergency Preparedness plan revealed that they lacked a policy regarding the role of the facility under a waiver declared by the Secretary. Facilities must develop and implement policies and procedures that describe its role in providing care and collaborating with local emergency officials at alternate care sites during emergencies. Additionally, there was no policy regarding the facility's role in emergencies under a waiver declared by the Secretary, in accordance with section 1135 of the Act. An example, including but not limited to, licensure for physicians or others to provide services in the affected state. In an interview on 2/22/18 at approximately 11:30am, the Administrator stated that the plan identifies two schools as alternate care sites and that he would include the roles of the facility in the policy.

Plan of Correction: ApprovedMarch 8, 2018

I. IMMEDIATE CORRECTIVE ACTION
No residents were identified in the Statement of Deficiencies.
The Administrator of Regal Heights reviewed facility?s current Emergency Preparedness Manual and revised to incorporate the new 1135 waiver policy and procedure.
II. IDENTIFICATION OF OTHER RESIDENTS
All residents have been identified as potentially being affected by this practice.
III. SYSTEMIC CHANGES
Administration will develop and provide a policy and procedure for the provision of care, if the facility needed to evacuate to an alternate care site under a waiver declared by the secretary. The policy and procedure will include plans on the procedures to relocate to an alternate care site. The Administration will also include the role of the facility under a waiver declared by the Secretary in accordance with section 1135. The policies will meet all applicable codes, rules, and regulations.
The In-service Coordinator will provide additional education, as needed, on the new 1135 Waiver Policy. Training on the 1135 Waiver Policy will be included in all staff and volunteer orientation and will be reviewed during drills, with all policy changes and on an as needed basis. Record of attendance will be available in the In-service classroom.
IV. QUALITY ASSURANCE
The Administrator will report any updates to the Emergency Preparedness Manual, including those related to 1135 waivers and the annual review to the QAPI Committee on a quarterly basis for evaluation and follow-up.
Responsible party: Administrator & In-service Coordinator

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 22, 2018
Corrected date: April 20, 2018

Citation Details

2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard or the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 6.2.1 Components of standpipe and hose systems shall be visually inspected annually or as specified in Table 6.1.1.2. 2011 NFPA 25: Table 6.1.1.2 Summary of Standpipe and Hose Systems Inspection, Testing, and Maintenance. Test Item Frequency Reference Hose 5 years/ 3 years NFPA 1962 2008 NFPA 1962: 4.3.2 In-service hose designed for occupant use only shall be removed and service-tested as specified in Chapter 7 at intervals not exceeding 5 years after the date of manufacturer and every 3 years thereafter. Based on observation and staff interview, the facility did not test hoses as per NFPA 25 & NFPA 1962. This was noted within two of two exit stairs serving eight of eight floors. The findings are: On 2/21/18 between 8:45am- 2:00pm during the recertification survey, hoses within Stairs A & B on eight of eight floors were noted with manufacture dates of 1999. At the time of the survey, the facility could not provide documentation indicating that the hoses were tested since the date of manufacture. In an interview on 2/21/18 at approximately 9:05am, the Director of Environmental Services stated that she will try and have the hoses removed. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 6.2.1 & Table 6.1.1.2 2008 NFPA 1962: 4.3.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 8, 2018

I. IMMEDIATE CORRECTIVE ACTION
No residents were identified in the Statement of Deficiencies.
The Director of Environmental services conducted a survey of all standpipe hoses and verified all hoses will be replaced.
II. IDENTIFICATION OF OTHER RESIDENTS
All residents have been identified as potentially being affected by this practice.
III. SYSTEMIC CHANGES
All Standpipe hoses will be inspected and replaced throughout the facility.
The Director of Environmental Services will contract with a qualified fire system company that will conduct monthly, semi-annual, annual, 3 year, and 5 year inspections of all standpipe hoses as part of the facilities established preventive maintenance program and record all inspections in the facilities Records & Logs.
All negative findings will be corrected immediately.
IV. QUALITY ASSURANCE
The Director of Environmental Services will report on all inspections of the standpipe hoses to the QAPI Committee on a quarterly basis.
Responsible party: Administrator, Director of Environmental Services and Maintenance