Cuba Memorial Hospital Inc SNF
November 16, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed 11/16/18, the pharmacist did not report drug irregularities to the attending physician and the facility's medical director and director of nursing, and that these reports were acted upon. Three (Residents #22, 25, 31) of six residents reviewed for monthly drug regimen reviews had issues. Specifically, the Consultant Pharmacist did not make recommendations regarding the ongoing use of a PRN (as needed) psychoactive medication (#22); the initiation of two antipsychotic medications while a resident was being treated for [REDACTED].#25); and a failed GDR with no documentation of the reason for the failure (Resident #31). The findings are: Refer to F758 s/s=D Free from Unnecessary [MEDICAL CONDITION] Medications/PRN Use Review of a pharmacy policy and procedure entitled Consultant Pharmacist Provider Requirements dated (MONTH) 2014 revealed the consultant pharmacist will establish a system whereby observations and recommendations regarding customers' (residents') drug therapy are communicated to those with authority and/ or responsibility to implement and/ or respond to the recommendations in an appropriate and timely fashion. The Consultant Pharmacist is to provide the facility with current information pertaining to drug therapy, including new drugs, indications and interactions, review the medication/drug regimen of each resident at least monthly, incorporating federally mandated standards of care in addition to other applicable professional standards, and document the review and findings in the resident's medical record. This includes the evaluation and reporting of adverse drug reactions. 1. Resident #25 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/13/18 revealed the resident was moderately cognitively impaired, understood and understands. There was no documentation of [MEDICAL CONDITION], behavioral symptoms, rejection of care or wandering behaviors. Section N of the MDS (Medications) documented that the resident received an antipsychotic medication for the past seven days; antipsychotics were received on a routine basis; and a GDR was attempted on 7/17/18. The current comprehensive care plan (CCP) (with a start date of 11/15/17) documented that the resident receives antipsychotic and antidepressant medications related to agitation and a history of depression. Approaches include administering medications as ordered; attempt a gradual dose reduction in two separate quarters the first year, then yearly thereafter unless clinically contraindicated; monitoring the resident's behaviors and response to medications; obtain pharmacy consultant reviews; and review for continued need at least quarterly. Review of Nursing Progress Notes dated 6/4/18 to 6/5/18 revealed the resident was worried about dying, that she was on a list to be put down, and she thought the facility was giving her embalming fluid with her medications. On 6/5/18, the resident was seen by the MD who ordered a U/A (urinalysis) and urine C&S (culture and sensitivity- a test to find germs (such as bacteria or fungus) that can cause infection). Orders were obtained to start [MEDICATION NAME] at HS (hour of sleep). A Physician Note dated 6/5/18 documented that the resident was having delusional thoughts and becoming psychotic about her death. She has suffered from a UTI before. Because of her Alzheimer's dementia, it is possible to have a psychotic feature and it is possible that she might be having a UTI. Plan to try a new dose of [MEDICATION NAME] 25 mg at bedtime and get a urine culture. A Nursing Progress Note dated 6/6/18 documented that new orders were received to start Sentra DS (antibiotic medication) one tablet po (by mouth) daily for seven days for a UTI (urinary tract infection). A Physician Note dated 6/11/18 revealed the resident was seen due to altered mentation and confusion. The urine culture was positive, resident still has some mental confusion and she is irritated. Plan to change the antibiotic to [MEDICATION NAME] (antibiotic) 250 mg po BID (twice a day) for seven days and encourage fluids. Review of Nursing Progress notes dated 6/7/18 through 6/22/18 revealed there was no documentation of behaviors, delusions or complaints of pain with urination. A Social Work Progress Note dated 6/18/18 revealed the resident appeared to be doing better on [MEDICATION NAME], was being treated for [REDACTED]. Nursing Progress Notes revealed the following: - 6/23/18 and 6/24/18 - The resident complained of pain and burning with urination and fluids were encouraged - 6/28/18 and 6/29/18 - The resident was showing signs of paranoia. - 7/2/18 -[MEDICATION NAME](antibiotic) started for UTI. - 7/4/18 to 7/7/18 - Self-propelling around the unit going into other residents' rooms. Refusing to take medications. As the day progressed on 7/7/18, the resident became more confused. A new order was obtained for [MEDICATION NAME] (antipsychotic medication) 0.5 mg PO (by mouth) BID (twice a day). - 7/10/18 - New order for UA/ CS. Review of the Physician Report for the urine cultures dated 6/5/18 and 6/29/18 revealed the resident was positive for a UTI. Review of the resident's Medication Administration History dated 6/1/18 to 6/30/18 revealed the resident received [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] DS) 800-160 mg tablet once a day for UTI from 6/7/18 to 6/11/18 and then was started on [MEDICATION NAME] 250 mg BID for UTI from 6/11/18 to 6/17/18. In addition, [MEDICATION NAME] 25 mg QD for generalized anxiety disorder from 6/5/18 to 6/30/18. Review of the Medication Administration History for (MONTH) 1, (YEAR) through (MONTH) 15, (YEAR) revealed the resident received: - [MEDICATION NAME] 25 mg QD for generalized anxiety disorder. - [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg BID from 7/31/18 to 11/8/18 and decreased to 0.125 mg BID from 11/8/18 to 11/14/18. - [MEDICATION NAME] was discontinued on 11/15/18. Review of the Pharmacy Medication Regimen Review from 12/8/17 through 11/8/18 revealed there was no documentation regarding the start of [MEDICATION NAME] or [MEDICATION NAME]. The 8/15/18 review documented GDR- [MEDICATION NAME]. During an interview on 11/16/18 at 9:11 AM, the Social Worker (SW) stated, The Behavioral Committee meets monthly to discuss the residents who are on an anti-psychotic medication. We should have done a medical work up first before starting her on an antipsychotic medication, but sometimes the MD does not agree, and we have to follow the orders. During an interview of 11/16/18 at 10:01 AM, the Medical Director stated, Yes I do review recommendations made by the Behavior Committee and the Pharmacist. During an interview on 11/16/18 at 11:16 AM, the DON stated, I would expect the Pharmacist to make his recommendation at the Behavioral Meeting and in his monthly reports. During an interview on 11/16/18 at 12:45 PM, the Administrator stated, There are no Pharmacy notes to the attending Physician regarding recommendations made for this resident for the [MEDICATION NAME] and [MEDICATION NAME]. During a telephone interview on 11/16/18 at 12:58 PM, the Consultant Pharmacist stated, Recommendations to prescribers for GDR are decided at the monthly behavior meetings. My monthly Medication Regime Review notes are briefer and contain information that may have been discussed at the behavior meetings. I do not write specific recommendations in my notes regarding antipsychotic medications. If a patient has a UTI and has a behavioral issue we will bring that up at the next behavioral meeting. No, I did not write any recommendations to stop the [MEDICATION NAME] or the [MEDICATION NAME]. I would not particularly write a recommendation to the physician. 2. Resident #31 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. There was no documentation of [MEDICAL CONDITION], behavioral symptoms, rejection of care or wandering. Section N of the MDS (Medications) documented that the resident received an antipsychotic medication for the past seven days, antipsychotics were received on a routine basis and a GDR was attempted on 9/18/18. No GDR was documented by a physician as clinically contraindicated. The current CCP (with a start date of 11/15/17) documented that the resident had [MEDICAL CONDITION] with behaviors and [MEDICAL CONDITION], received antipsychotic and antidepressant medications related to depression and approaches include administering medication per MD order and observing for signs of effectiveness/side effects. The CCP revealed a GDR was attempted on 9/18/18 and [MEDICATION NAME] was decreased from 50 mg to 25 mg at HS (hour of sleep). On 9/21/18 the GDR failed, and the [MEDICATION NAME] was increased to 50 mg at HS. Additional review of the Care Plan revealed the resident had behaviors and at times can be aggressive and verbally abusive towards staff. Additional care plan approaches include diverting the resident's behavior by taking walks: offering activities per choice and maintaining a calm environment and approach with the resident. In addition, staff are to seat the resident where frequent observation is possible and when the resident becomes socially inappropriate/ disruptive, move to a quiet, calm environment. Review of Nursing Progress Notes dated 9/2/18 to 9/20/18 revealed intermittent behaviors included refusing to sit at the table after dinner; running from the dining room; wandering into other residents' rooms; removing clothing; and restlessness. There were no behaviors documented from 9/4/18 to 9/12/18 and 9/14/18 through 9/17/18. On 9/18/18, [MEDICATION NAME] was decreased to 25 mg at HS. On 9/19/18 and 9/20/18, the resident was restless and removed his clothes twice. A Nursing Progress Note dated 9/21/18 at 11:52 AM documented the resident was more restless and anxious and the [MEDICATION NAME] GDR failed. A new order was received from the MD to resume [MEDICATION NAME] 50 mg at HS. Review of Medication Administration History dated 9/1/18 through 9/30/18 revealed resident received [MEDICATION NAME] 50 mg from 9/1/18 through 9/17/18 and then 9/21/18 through 9/30/18. [MEDICATION NAME] 25 mg from 9/18/18 to 9/20/18. Review of a Physician Note dated 10/16/18 revealed there was no documentation regarding the failed [MEDICATION NAME] GDR from 9/18/18 to 9/20/18. Behavioral Worksheets revealed documentation dated 5/8/18 related to [MEDICATION NAME] 50 mg with target behavior/symptoms of agitation and aggression. A Behavioral Worksheet dated 9/11/18 documented the recommendation for a GDR of [MEDICATION NAME] to 25 mg at HS. No other Behavioral Worksheets were available for Resident #31. Review of Pharmacy Medication Regimen Reviews from 2/15/18 through 11/8/18 revealed a notation dated 10/4/18 no irregularities - GDR failed with Quetiapine. During an interview via telephone on 11/16/18 at 1:20 PM, the Consultant Pharmacist stated, This resident's GDR would have been discussed at the Behavioral Meeting. No, I did not write anything regarding the failed GDR, as to why it failed. 3. Resident #22 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident was cognitively intact, understands and is understood. Review of Physician order [REDACTED]. and the order remained in effect until 11/16/18. In addition, the orders included [MEDICATION NAME] (antipsychotic medication) 150 mg intramuscular (IM) every two weeks on Sunday from 9/22/17 to 6/26/18. The [MEDICATION NAME] was decreased to 100 mg IM every two weeks until 8/12/18, and then increased to 150 mg. Review of the current CCP dated 9/5/18 revealed a problem related to [MEDICAL CONDITION] drug use was initiated on 8/29/17 because the resident was receiving antidepressant, antipsychotic, and anti-anxiety medications related to [MEDICAL CONDITION], major [MEDICAL CONDITION], and anxiety. There was no rationale documented in the CCP for the use of IM [MEDICATION NAME] and there were no resident centered non-pharmacologic interventions. On 4/3/17 a problem of mood state documented the resident had an absence of personal contact with family/friends related to his [DIAGNOSES REDACTED]. Physician Provider Notes dated 9/25/17 to 10/16/18 documented the resident had depression, anxiety and [MEDICAL CONDITION]. There was no assessment/ plan documented related to the rationale for the PRN [MEDICATION NAME] and IM [MEDICATION NAME], no identification of specific target behaviors, and no documentation regarding the effectiveness of the medications. Psychiatric provider notes from 8/2017 to 11/2018 were requested from Administrative personnel, and two Progress Notes from the MSW (Masters in Social Work) dated 8/29/18 and 10/28/18 were provided as follows: - 8/29/18 - The resident had a medication reduction on 6/26/18 and experienced an increase in psychiatric symptoms ranging from visual to auditory hallucinations. [MEDICATION NAME] was increased to the current level of 150 mg IM every two weeks. The resident has [MEDICAL CONDITIONS], depression, and anxiety and reports that he heard voices which tell him they are going to get him. The resident stated the PRN medication comes in handy when he needs it. In addition to the [MEDICATION NAME], the resident has [MEDICATION NAME] ([MEDICATION NAME] - anxiolytic medication) 0.5 mg three times a day for anxiety. There were no recommendations regarding the resident's psychoactive medications. - 10/28/18 - Resident assessed for severity of hallucinations, both auditory and visual. The resident reported that voices are telling him they are going to kill him or get him faded and the [MEDICATION NAME] works in assisting him control his anxiety. Clinical recommendations documented that the clinician will continue to address the severity of the resident's psychiatric stability with medications that provide the opportunity to use as needed medications. Will follow-up during periods of psychiatric decompensation. A request for the past year of Behavior Committee Worksheets from the ADON yielded one worksheet dated 10/9/18. The Behavior Monitoring Worksheet dated 10/9/18 documented the resident has [MEDICAL CONDITION], depression, and anxiety and receives [MEDICATION NAME] 150 mg every two weeks and [MEDICATION NAME] 1.0 mg every eight hours as needed. The last GDR attempt failed, and the [MEDICATION NAME] was increased back to 150 mg on 8/12/18. The committee recommended that as the [MEDICATION NAME] tapers off, the [MEDICATION NAME] is used for the safety/ comfort of the resident and he requests the [MEDICATION NAME] when he needs it. The pharmacist is to write the recommendation. Review of the Monthly Medication Regimen Review in the Resident Progress Notes, by the Consultant Pharmacist from 12/9/17 to 11/2018, documented no irregularities. A Social Work Note dated 7/3/18 revealed the resident was assessed regarding his decision not to have an amputation. The resident has thought disorder, depression, limited insight and anxiety related to restlessness and irrational fears. Delusional content situationally present regarding paranoia and auditory hallucinations. No current visual hallucinations and receives [MEDICATION NAME] 150 mg injectable every Sunday and [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg three times a day for anxiety. The Consultant Pharmacist Summary of Recommendations for nursing and medical staff dated 10/14/18 documented that the resident had a GDR on 6/26/18 of [MEDICATION NAME] 150 mg IM every two weeks reduced to 100 mg IM every two weeks. On 8/12/18 the [MEDICATION NAME] IM was increased to 150 mg IM every two weeks. The recommendation from the committee was to use the [MEDICATION NAME] in the last days of the long acting [MEDICATION NAME] injection and nursing staff and the physician should write a note regarding this for the safety of the resident. Review of the Medication Administration Records revealed the resident received the following doses of PRN [MEDICATION NAME]: - Two doses monthly from 1/2018 through 4/2018 - 5/2018 - 15 doses - 6/2018 - 9 doses - 7/2018 - 43 doses - 8/2018 - 19 doses - 9/2018 - 11 doses - 10/2018 - 11 doses - 11/1/18 to 11/16/18 - 9 doses Review of Nursing Progress Notes and the Medication Administration History, both dated 5/2018 to 11/2018, revealed there was no documentation of the resident's specific symptoms and behaviors prior to the administration of PRN [MEDICATION NAME] and lack of implementation of nonpharmacologic interventions prior to its use as follows: - 5/18 - one nursing behavior note was documented, 15 doses of PRN [MEDICATION NAME] were administered. - 6/18 - one SW progress note and no supporting nursing progress notes for the administration of 9 doses of PRN [MEDICATION NAME]. - 7/18 - Six day of behavior notes documented for 43 doses of administered PRN [MEDICATION NAME]. - 8/18 - Six days of notes for 9 doses of administered PRN [MEDICATION NAME] - 9/18 - One nursing progress note for 11 doses of PRN [MEDICATION NAME] was administered. - 10/18 - One nursing behavior progress note and 11 doses of PRN [MEDICATION NAME] were administered. - 11/18 - No nursing behavior progress notes and 9 doses of PRN [MEDICATION NAME] were administered. During an interview on 11/16/18 at 11:01 AM, the Social Worker stated that the interdisciplinary team had not questioned the use of the IM [MEDICATION NAME], she thought the MD liked the long-[MEDICATION NAME] effect of the IM versus the oral [MEDICATION NAME] and she believed the resident did well on the IM medication. During an interview on 11/16/18 at 11:39 AM, the ADON stated that she is part of the behavioral committee which meets monthly and stated the resident uses the PRN [MEDICATION NAME] when the IM [MEDICATION NAME] wears off. She did not know why the resident was on IM [MEDICATION NAME] versus oral [MEDICATION NAME]. The ADON stated that she witnessed one episode of auditory hallucination when the resident told her he heard voices that staff are trying to poison him. During an interview on 11/15/18 at 12:05 PM, the Physician stated that he is informed of pharmacy recommendations from the pharmacist and the behavioral committee. The physician stated he was not aware that the PRN [MEDICAL CONDITION] medication ([MEDICATION NAME]) should only be ordered for 14 days. During an interview on 11/16/18 at 9:46 AM, the physician stated that the resident is on IM [MEDICATION NAME] at the psychiatrist's recommendation and he did not receive any pharmacy recommendation regarding the use of the PRN [MEDICATION NAME] or IM [MEDICATION NAME] During an interview on 11/16/18 1:00 PM, the Consultant Pharmacist stated that when he performs a medication regimen review he is looking to see if the resident is getting the right drug and the right dose, via the correct route. The Consultant Pharmacist stated he participates in the behavioral meeting when the interdisciplinary team discusses the resident. The Consultant Pharmacist stated that as a consultant he can't really give a good recommendation until the interdisciplinary team discusses the resident because a lot of things are not documented. The Consultant Pharmacist did not know why the resident was on IM [MEDICATION NAME] versus an oral daily medication, he assumed it was for compliance and stated that the resident used the as needed [MEDICATION NAME] one day a week when the IM [MEDICATION NAME] is wearing off. He got that information from the behavioral meeting, he did not review the Medication Administration Record [REDACTED]. 415.18(c)(2)

Plan of Correction: ApprovedJanuary 18, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In order to be in compliance with 483.45(c)(1)(2)(4)(5) Drug Regimen Review, Report Irregular, Act On the facility did the following. Resident #25, resident #31, and resident #22 were reviewed and assessed by the Director of Nursing, Medical Director, and Pharmacy Consultant for unnecessary drugs.
Resident #25- A [MEDICATION NAME] taper was completed on resident #25 on 11/14/18. Per pharmacist recommendation attending physician reduced her current dose of [MEDICATION NAME] by half. Resident will be monitored for her typical symptoms of [MEDICAL CONDITION] including paranoia and delusions. In the absence of these, further reduction will be instituted with the ultimate goal of discontinuance of the medication.
Resident#31-: A previous GDR was deemed failed due to onset of increased restlessness and antisocial behavior. Another attempt was initiated today following Pharmacist and MD review. [MEDICATION NAME] is decreased by half, resident will be monitored for increased sleeplessness, constant movements, attempts to self ambulate and removal of clothing as well as wandering during the nite. The goal being to determine the lowest effective dose and possible discontinuance
Resident #22-: Pharmacy and MD review completed. Attending physician saw resident #22 and reviewed recommendations from Consultant Pharmacist. Orders were received to begin [MEDICATION NAME] taper with goal to discontinue. Attending physician will attempt alternate medications for bridging to next [MEDICATION NAME] if necessary.
A new facility form, The [MEDICAL CONDITION] Medication Tracking form was completed on each resident addressing the diagnosis, targeted behavior, possible underlying causes of behavior, non-pharmacological interventions, risk/benefit consent of resident/legal representative for the specific med, documentation of the most recent GDR with outcome or if GDR deemed not appropriate physician documentation for maintaining current dose.
The [MEDICAL CONDITION] Medication Tracking Tool will serve as the assessment for all [MEDICAL CONDITION] medications upon initiation and during the duration of the prescription. The tracking tool will become part of the resident's comprehensive care plan and will be updated at least quarterly for each medication until the medication is discontinued.
The Pharmacy Consultant Requirements Policy and Procedure was updated to state the following.
The Pharmacy consultant will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports will be acted upon.Irregularities will include any drug that classified as a [MEDICAL CONDITION] medication and may be an unnecessary drug. Any irregularities noted by the pharmacist during this review will be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. The attending physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action will be taken to address it. If there is to be no change in the medication, the attending physician will document his or her rationale in the resident's medical record.
The Medical Director, Director of Nursing,Pharmacy Consultant and all members of the comprehensive care planning team including RN Unit Managers, Social Worker, Activity Director, ADON, DON, Dietician, and Director of Therapy were educated on the updated policy by the DON. In addition all licensed nursing staff on SNF were educated on the [MEDICAL CONDITION] Medication Tracking Tool Procedure by the RN Education Coordinator.
The Director of Nursing will review all of the Pharmacy Consultant Recommendations monthly to ensure compliance with the policy and provide a written report to the Administrator monthly for 6 months and then quarterly thereafter. Additionally the results of the monthly reports will be reported at the facilities regularly scheduled QA/PI Meetings.
Person Responsible: Director of Nursing

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

Based on observation, interview and record review conducted during the Standard survey completed on 11/16/18, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included the lack of backflow prevention on the drain of the dishwashing machine. This affected one of one main dishwashing machine. The finding is: 1. Observation in the Main Kitchen on 11/13/18 at 11:07 AM revealed the drain to the dishwashing machine was a two-inch diameter accordion-style flexible hose that extended approximately two inches down into a nearby floor drain, which provided a potential cross connection between the dishwashing machine and the sewage system floor drain plumbing. The dishwashing machine manufacturer Owner's Manual documented, If the unit uses a gravity drain, it has to drain in an open floor drain. The section that provides information about this model of dishwashing machine documented, This dishwasher has a gravity drain. During an interview on 11/15/18 at 10:00 AM, the Maintenance Supervisor stated he spoke to an outside dishwasher maintenance technician today who advised the dishwashing machine is equipped with a check valve (one-way directional valve) on the fill side to prevent dishwasher water from entering the facility's potable water supply, but the machine's gravity drain is not equipped with a check valve to prevent sewage from entering the machine. The technician also advised to prevent sewage from entering the machine, that an open drain is recommended 415.14(h) 14-1.140, 14-1.141

Plan of Correction: ApprovedDecember 17, 2018

In order to be compliant with 483.90 the facility did the following. The dishwasher gravity drain was switched to an open drain per the service technicians recommendation during the annual survey to ensure sewage does not enter the machine on the drain side. Education on the 483.90 will be conducted by the administrator with all maintenance staff and documented.The open drain will be inspected weekly by the Maintenance Supervisor or his designee for six months and monthly thereafter to ensure it is working properly. The results of these inspections will be presented at the facility's monthly Safety Committee Meeting for review.
Person responsible: Maintenance Supervisor

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 11/16/18, the facility did not ensure that residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinical contraindicated, in an effort, to discontinue these drugs; PRN (as needed) orders for [MEDICAL CONDITION] drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Three (Residents #22, 25, 31) of six residents reviewed for [MEDICAL CONDITION] medications had issues involving the lack of a medical workup prior to initiating ongoing treatment with an antipsychotic medication (#25), lack of implementation of nonpharmacologic interventions at the time of a GDR and a subsequent increase in the dose of an antipsychotic medication without adequate indications (#31) and a PRN [MEDICAL CONDITION] medication was administered more than 14 days without physician evaluation of the resident (#22). In addition, the physician did not document a rationale and indications for the continued use of an intramuscular (IM) injection of an antipsychotic medication (#22). The findings are: Refer to F756 s/s=E - Drug Regimen Review, Report Irregularities, Act on Review of a policy and procedure (P&P) entitled Behavior Assessment and Monitoring dated 11/1/2017 revealed it is the policy of the facility to identify and manage problematic behavior appropriately. Elders (residents) will have minimal complications associated with the management of problematic behavior and the facility will comply with regulatory requirements related to the use of medications to manage problematic behaviors. Additional review of the P&P revealed the following: - Nursing staff will identify, document, and inform the physician about an elder's mental; status, behavior and cognition including onset, duration and frequency of problematic behaviors or changes in behavior, cognition, mood or any participating or relevant factions (e.g. medication changes, infection or recent transfer from the hospital). - Staff will identify and discuss with the physician situations where non-pharmacologic approaches are indicated and will institute such measures to the extent possible. - Staff will document the following information about specific problem behaviors: number and frequency of episodes; preceding or precipitating factors; interventions attempted (if psychoactive drug is used as an intervention, institute appropriate psychoactive drug monitoring) and outcomes associated with the interventions. - If psychoactive medications are used to treat behavioral symptoms of dementia the interdisciplinary team and physician will periodically reconsider their indication and consider whether they can be tapered or document why tapering cannot or should not be attempted. - The IDT (interdisciplinary team) will meet monthly to review psychotic medications, non-pharmacological interventions and the need for GDR. 1. Resident #25 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/13/18 revealed the resident was moderately cognitively impaired, understood and understands. There was no documentation of [MEDICAL CONDITION], behavioral symptoms, rejection of care or wandering behaviors. Section N of the MDS (Medications) documented that the resident received an antipsychotic medication for the past seven days; antipsychotics were received on a routine basis; and a GDR was attempted on 7/17/18. The current comprehensive care plan (CCP) (with a start date of 11/15/17) documented that the resident receives antipsychotic and antidepressant medications related to agitation and a history of depression. Approaches include administering medications as ordered; attempt a gradual dose reduction in two separate quarters the first year, then yearly thereafter unless clinically contraindicated; monitoring the resident's behaviors and response to medications; obtain pharmacy consultant reviews; and review for continued need at least quarterly. Review of Nursing Progress Notes dated 6/4/18 to 6/5/18 revealed the resident was worried about dying, that she was on a list to be put down, and she thought the facility was giving her embalming fluid with her medications. On 6/5/18, the resident was seen by the MD who ordered a U/A (urinalysis) and urine C&S (culture and sensitivity- a test to find germs (such as bacteria or fungus) that can cause infection). Orders were obtained to start [MEDICATION NAME] at HS (hour of sleep). A Physician Note dated 6/5/18 documented that the resident was having delusional thoughts and becoming psychotic about her death. She has suffered from a UTI before. Because of her Alzheimer's dementia, it is possible to have a psychotic feature and it is possible that she might be having a UTI. Plan to try a new dose of [MEDICATION NAME] 25 mg at bedtime and get a urine culture. A Nursing Progress Note dated 6/6/18 documented that new orders were received to start [MEDICATION NAME] DS (antibiotic medication) one tablet po (by mouth) daily for seven days for a UTI (urinary tract infection). A Physician Note dated 6/11/18 revealed the resident was seen due to altered mentation and confusion. The urine culture was positive, resident still has some mental confusion and she is irritated. Plan to change the antibiotic to [MEDICATION NAME] (antibiotic) 250 mg po BID (twice a day) for seven days and encourage fluids. Review of Nursing Progress notes dated 6/7/18 through 6/22/18 revealed there was no documentation of behaviors, delusions or complaints of pain with urination. A Social Work Progress Note dated 6/18/18 revealed the resident appeared to be doing better on [MEDICATION NAME], was being treated for [REDACTED]. Nursing Progress Notes revealed the following: - 6/23/18 and 6/24/18 - The resident complained of pain and burning with urination and fluids were encouraged - 6/28/18 and 6/29/18 - The resident was showing signs of paranoia. - 7/2/18 -[MEDICATION NAME](antibiotic) started for UTI. - 7/4/18 to 7/7/18 - Self-propelling around the unit going into other residents' rooms. Refusing to take medications. As the day progressed on 7/7/18, the resident became more confused. A new order was obtained for [MEDICATION NAME] (antipsychotic medication) 0.5 mg PO (by mouth) BID (twice a day). - 7/10/18 - New order for UA/ CS. Review of the Physician Report for the urine cultures dated 6/5/18 and 6/29/18 revealed the resident was positive for a UTI. Review of the Medication Administration History for (MONTH) 1, (YEAR) through (MONTH) 15, (YEAR) revealed the resident received: - [MEDICATION NAME] 25 mg QD for generalized anxiety disorder. - [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg BID from 7/31/18 to 11/8/18 and decreased to 0.125 mg BID from 11/8/18 to 11/14/18. - [MEDICATION NAME] was discontinued on 11/15/18. Review of the Pharmacy Medication Regimen Review from 12/8/17 through 11/8/18 revealed there were no notations regarding the start of [MEDICATION NAME] or [MEDICATION NAME]. The 8/15/18 review documented GDR- [MEDICATION NAME]. During an interview on 11/16/18 at 9:11 AM, the Social Worker (SW) stated, The Behavioral Committee meets monthly to discuss the residents who are on an anti-psychotic medication. We should have done a medical work up first before starting her on an antipsychotic medication, but sometimes the MD does not agree, and we have to follow the orders. During an interview on 11/16/18 at 9:31 AM, the Registered Nurse (RN#1) Assistant Director of Nursing (ADON) stated, If a resident is showing signs of a UTI, I would have them worked up first to see if that was the reason for the delusions or behaviors. I would wait for the urine culture to come back and if positive get an order for [REDACTED]. When interviewed on 11/16/18 at 10:01 AM, the Medical Director stated, Yes, a resident could have delusional episodes if they have a urinary tract infection. I placed her on both because sometimes it takes a while, sometimes a week for the results to come back for a UTI. If the resident is positive for the UTI, I would then look at the antipsychotic medication and possibly discontinue it. I probably should have discontinued the [MEDICATION NAME]. I think the Nurse Practitioner placed her on the [MEDICATION NAME] in (MONTH) and I do not know why. During an interview on 11/16/18 at 11:16 AM, the DON stated, Normally I would not have the doctor order an antipsychotic medication if we felt that the resident had an UTI. I would like to see if once the UTI is cleared up, if the behaviors or delusions stop. This resident was very distraught at the time. 2. Resident #31 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. There was no documentation of [MEDICAL CONDITION], behavioral symptoms, rejection of care or wandering. Section N of the MDS (Medications) documented that the resident received an antipsychotic medication for the past seven days, antipsychotics were received on a routine basis and a GDR was attempted on 9/18/18. No GDR was documented by a physician as clinically contraindicated. The current CCP (with a start date of 11/15/17) documented that the resident had [MEDICAL CONDITION] with behaviors and [MEDICAL CONDITION], received antipsychotic and antidepressant medications related to depression and approaches include administering medication per MD order and observing for signs of effectiveness/side effects. The CCP revealed a GDR was attempted on 9/18/18 and [MEDICATION NAME] was decreased from 50 mg to 25 mg at HS (hour of sleep). On 9/21/18, the GDR failed and the [MEDICATION NAME] was increased to 50 mg at HS. Additional review of the Care Plan revealed the resident had behaviors and at times can be aggressive and verbally abusive towards staff. Additional care plan approaches include diverting the resident's behavior by taking walks: offering activities per choice and maintaining a calm environment and approach with the resident. In addition, staff are to seat the resident where frequent observation is possible and when the resident becomes socially inappropriate/ disruptive, move to a quiet, calm environment. Review of Nursing Progress Notes dated 9/2/18 to 9/20/18 revealed intermittent behaviors included refusing to sit at the table after dinner; running from the dining room; wandering into other residents' rooms; removing clothing; and restlessness. There were no behaviors documented from 9/4/18 to 9/12/18 and 9/14/18 through 9/17/18. On 9/18/18, [MEDICATION NAME] was decreased to 25 mg at HS. On 9/19/18 and 9/20/18, the resident was restless and removed his clothes twice. A Nursing Progress Note dated 9/21/18 at 11:52 AM documented the resident was more restless and anxious and the [MEDICATION NAME] GDR failed. A new order was received from the MD to resume [MEDICATION NAME] 50 mg at HS. Review of the Medication Administration History dated 9/1/18 through 9/30/18 revealed the resident received [MEDICATION NAME] 50 mg from 9/1/18 to 9/17/18 and 9/21/18 through 9/30/18. [MEDICATION NAME] 25 mg was administered from 9/18/18 to 9/20/18. Review of a Physician Note dated 10/16/18 revealed there was no documentation regarding the failed [MEDICATION NAME] GDR from 9/18/18 to 9/20/18. Behavioral Worksheets revealed documentation dated 5/8/18 related to [MEDICATION NAME] 50 mg with target behavior/symptoms of agitation and aggression. A Behavioral Worksheet dated 9/11/18 documented the recommendation for a GDR of [MEDICATION NAME] to 25 mg at HS. No other Behavioral Worksheets were available for Resident #31. During an interview on 11/15/18 at 1:17 PM, the RN (#2) Unit Manager stated, We try to monitor for two weeks for increased behaviors (after a GDR). I was not here but reviewing the Nursing Progress Notes there are no non-pharmacological interventions documented and the restlessness and undressing are his normal behaviors. During an interview on 11/16/18 at 9:11 AM, the SW stated, This resident has had some big behaviors. We should have documented more on the behaviors he was having and the non-pharm interventions we were using on him. When interviewed on 11/16/18 at 9:39 AM, the ADON stated, I do not think he was having any more increased agitation than his normal. The documentation really doesn't have any behaviors other than what he was already experiencing. I am not sure why we increased the [MEDICATION NAME] after just three days. During an interview on 11/16/18 at 9:49 AM, the DON stated, When someone has a GDR, we are looking for an increase in behaviors and agitation before increasing them back to the higher dose. There is no documentation and we need to revisit that GDR again with this resident. During an interview on 11/16/18 at 9:55 AM, the Medical Director stated, It does take at least two weeks for an antipsychotic medication to be out of a person's system. I think they called me and stated he was having behaviors and asked to restart the medication, saying the GDR failed. I take the word of the staff. No, I usually do not follow up when I come in, but I think from here forward if they call me and ask for a change I am going to have them put that resident on (the schedule) for me to see. We do have a committee here for GDR. 3. Resident #22 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident was cognitively intact, understands and is understood. Review of Physician order [REDACTED]. and the order remained in effect until 11/16/18. In addition, the orders included [MEDICATION NAME] (antipsychotic medication) 150 mg intramuscular (IM) every two weeks on Sunday from 9/22/17 to 6/26/18. The [MEDICATION NAME] was decreased to 100 mg IM every two weeks until 8/12/18, and then increased to 150 mg. Review of the current CCP dated 9/5/18 revealed a problem related to [MEDICAL CONDITION] drug use was initiated on 8/29/17 because the resident was receiving antidepressant, antipsychotic, and anti-anxiety medications related to [MEDICAL CONDITION], major [MEDICAL CONDITION], and anxiety. There was no rationale documented in the CCP for the use of IM [MEDICATION NAME] and there were no resident centered non-pharmacologic interventions. On 4/3/17 a problem of mood state documented the resident had an absence of personal contact with family/friends related to his [DIAGNOSES REDACTED]. Physician Provider Notes dated 9/25/17 to 10/16/18 documented the resident had depression, anxiety and [MEDICAL CONDITION]. There was no assessment/ plan documented related to the rationale for the PRN [MEDICATION NAME] and IM [MEDICATION NAME], no identification of specific target behaviors, and no documentation regarding the effectiveness of the medications. Psychiatric provider notes from 8/2017 to 11/2018 were requested from Administrative personnel, and two Progress Notes from the MSW (Masters in Social Work) dated 8/29/18 and 10/28/18 were provided as follows: - 8/29/18 - The resident had a medication reduction on 6/26/18 and experienced an increase in psychiatric symptoms ranging from visual to auditory hallucinations. [MEDICATION NAME] was increased to the current level of 150 mg IM every two weeks. The resident has [MEDICAL CONDITIONS], depression, and anxiety and reports that he heard voices which tell him they are going to get him. The resident stated the PRN medication comes in handy when he needs it. In addition to the [MEDICATION NAME], the resident has [MEDICATION NAME] ([MEDICATION NAME] - anxiolytic medication) 0.5 mg three times a day for anxiety. There were no recommendations regarding the resident's psychoactive medications. - 10/28/18 - Resident assessed for severity of hallucinations, both auditory and visual. The resident reported that voices are telling him they are going to kill him or get him faded and the [MEDICATION NAME] works in assisting him control his anxiety. Clinical recommendations documented that the clinician will continue to address the severity of the resident's psychiatric stability with medications that provide the opportunity to use as needed medications. Will follow-up during periods of psychiatric decompensation. A request for the past year of Behavior Committee Worksheets from the ADON yielded one worksheet dated 10/9/18. The Behavior Monitoring Worksheet dated 10/9/18 documented the resident has [MEDICAL CONDITION], depression, and anxiety and receives [MEDICATION NAME] 150 mg every two weeks and [MEDICATION NAME] 1.0 mg every eight hours as needed. The last GDR attempt failed and the [MEDICATION NAME] was increased back to 150 mg on 8/12/18. The committee recommended that as the [MEDICATION NAME] tapers off, the [MEDICATION NAME] is used for the safety/ comfort of the resident and he requests the [MEDICATION NAME] when he needs it. The pharmacist is to write the recommendation. A Social Work Note dated 7/3/18 revealed the resident was assessed regarding his decision not to have an amputation. The resident has thought disorder, depression, limited insight and anxiety related to restlessness and irrational fears. Delusional content situationally present regarding paranoia and auditory hallucinations. No current visual hallucinations and receives [MEDICATION NAME] 150 mg injectable every Sunday and [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg three times a day for anxiety. The Consultant Pharmacist Summary of Recommendations for nursing and medical staff dated 10/14/18 documented that the resident had a GDR on 6/26/18 of [MEDICATION NAME] 150 mg IM every two weeks reduced to 100 mg IM every two weeks. On 8/12/18 the [MEDICATION NAME] IM was increased to 150 mg IM every two weeks. The recommendation from the committee was to use the [MEDICATION NAME] in the last days of the long acting [MEDICATION NAME] injection and nursing staff and the physician should write a note regarding this for the safety of the resident. Review of the Medication Administration Records revealed the resident received the following doses of PRN [MEDICATION NAME]: - Two doses monthly from 1/2018 through 4/2018 - 5/2018 - 15 doses - 6/2018 - 9 doses - 7/2018 - 43 doses - 8/2018 - 19 doses - 9/2018 - 11 doses - 10/2018 - 11 doses - 11/1/18 to 11/16/18 - 9 doses Review of Nursing Progress Notes and the Medication Administration History, both dated 5/2018 to 11/2018, revealed there was no documentation of the resident's specific symptoms and behaviors prior to the administration of PRN [MEDICATION NAME] and lack of implementation of nonpharmacologic interventions prior to its use as follows: - 5/18 - one nursing behavior note was documented, 15 doses of PRN [MEDICATION NAME] were administered. - 6/18 - one SW progress note and no supporting nursing progress notes for the administration of 9 doses of PRN [MEDICATION NAME]. - 7/18 - Six day of behavior notes documented for 43 doses of administered PRN [MEDICATION NAME]. - 8/18 - Six days of notes for 9 doses of administered PRN [MEDICATION NAME] - 9/18 - One nursing progress note for 11 doses of PRN [MEDICATION NAME] was administered. - 10/18 - One nursing behavior progress note and 11 doses of PRN [MEDICATION NAME] were administered. - 11/18 - No nursing behavior progress notes and 9 doses of PRN [MEDICATION NAME] were administered. During an interview on 11/16/18 at 11:01 AM, the Social Worker stated that the interdisciplinary team had not questioned the use of the IM [MEDICATION NAME], she thought the MD liked the long-[MEDICATION NAME] effect of the IM versus the oral [MEDICATION NAME] and she believed the resident did well on the IM medication. During an interview on 11/16/18 at 11:39 AM, the ADON stated that she is part of the behavioral committee which meets monthly and stated the resident uses the PRN [MEDICATION NAME] when the IM [MEDICATION NAME] wears off. She did not know why the resident was on IM [MEDICATION NAME] versus oral [MEDICATION NAME]. The ADON stated that she witnessed one episode of auditory hallucination when the resident told her he heard voices that staff are trying to poison him. During an interview on 11/15/18 at 12:05 PM, the Physician stated that he is informed of pharmacy recommendations from the pharmacist and the behavioral committee. The physician stated he was not aware that the PRN [MEDICAL CONDITION] medication ([MEDICATION NAME]) should only be ordered for 14 days. During an interview on 11/16/18 at 9:46 AM, the physician stated that the resident is on IM [MEDICATION NAME] at the psychiatrist's recommendation and he did not receive any pharmacy recommendation regarding the use of the PRN [MEDICATION NAME] or IM [MEDICATION NAME]. During an interview on 11/15/18 at 11:17 AM, a Licensed Practical Nurse (LPN #1) stated the resident asks for the PRN [MEDICATION NAME] when he hears voices in his head and it makes him anxious. However, she has administered the [MEDICATION NAME] several times when the resident did not tell her what the voices and he looked anxious. During an interview on 11/15/18 at 11:37 AM, the Registered Nurse (RN #3) Unit Manager (UM) stated she has not participated in the behavioral meetings since she just started the UM position in 9/2018. The RN UM did not know why the resident was on injectable [MEDICATION NAME] versus an oral medication and stated that the PRN [MEDICATION NAME] is generally used at the end of the 2-week period for the IM [MEDICATION NAME] when the resident starts to hallucinate which causes him anxiety. The RN UM stated she has not witnessed this herself. 415.12(l)(1,2)(i)(a,c,d)(ii)

Plan of Correction: ApprovedJanuary 18, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In order to be in compliance with 483.45(c)(3)(e)(1)-(5) Free from Unnecessary [MEDICAL CONDITION] Meds/PRN Use the facility did the following. Resident #25, resident #31, and resident #22 were reviewed and assessed by the Director of Nursing, Medical Director, and Pharmacy Consultant for unnecessary drugs.
Resident #25- A [MEDICATION NAME] taper was completed on resident #25 on 11/14/18. Per pharmacist recommendation attending physician reduced her current dose of [MEDICATION NAME] by half. Resident will be monitored for her typical symptoms of [MEDICAL CONDITION] including paranoia and delusions. In the absence of these, further reduction will be instituted with the ultimate goal of discontinuance of the medication.
Resident#31-: A previous GDR was deemed failed due to onset of increased restlessness and antisocial behavior. Another attempt was initiated today following Pharmacist and MD review. [MEDICATION NAME] is decreased by half, resident will be monitored for increased sleeplessness, constant movements, attempts to self ambulate and removal of clothing as well as wandering during the nite. The goal being to determine the lowest effective dose and possible discontinuance
Resident #22-: Pharmacy and MD review completed. Attending physician saw resident #22 and reviewed recommendations from Consultant Pharmacist. Orders were received to begin [MEDICATION NAME] taper with goal to discontinue. Attending physician will attempt alternate medications for bridging to next [MEDICATION NAME] if necessary.

A new facility form, The [MEDICAL CONDITION] Medication Tracking form was completed on each resident addressing the diagnosis, targeted behavior, possible underlying causes of behavior, non-pharmacological interventions, risk/benefit consent of resident/legal representative for the specific med, documentation of the most recent GDR with outcome or if GDR deemed not appropriate physician documentation for maintaining current dose.
The [MEDICAL CONDITION] Medication Tracking Tool will serve as the assessment for all [MEDICAL CONDITION] medications upon initiation and during the duration of the prescription. The tracking tool will become part of the resident's comprehensive care plan and will be updated at least quarterly for each medication until the medication is discontinued. The [MEDICAL CONDITION] Medication Tracking Tool will be initiated by the licensed nurse receiving the prescription order. The members of the CCP Team will then review the form at morning report for completion and it will become part of the residents comprehensive care plan thereafter until it is discontinued.
All licensed clinical nursing staff, members of the CCP Team, Medical Director, DON, and Pharmacy Consultant will be educated on the new [MEDICAL CONDITION] Medication Monitoring Tool Policy and Procedure by the RN Education Coordinator.
The Quality Assurance Committee will monitor utilization of [MEDICAL CONDITION] medications at least quarterly with the goal of eliminating any unnecessary medications.

Person Responsible: Director of Nursing

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

Based on interview and record review conducted during the Standard survey completed on 11/16/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not have a Legionella water sampling plan in place for the facility's potable water system. This affected the entire building, including three (First, Second, and Third Floors) of three resident use floors. The finding is: 1. The facility's Legionella water sampling reports documented the reports were specifically for the testing of the cooling tower water. During an interview on 11/16/18 at 10:40 AM, the Administrator stated the facility has been conducting Legionella water sampling for its cooling tower, but has not yet begun Legionella water sampling of the potable water system. According to the New York State Department of Health's Health Advisory entitled, Regulation for the Protection Against Legionella dated 8/12/16, Part 4 of the New York State Sanitary Code Protection Against Legionella, effective (MONTH) 6, (YEAR). Subpart 4-2 of the regulations require all general hospitals and residential health care facilities to adopt and implement a Legionella culture sampling and management plan for their potable water systems by (MONTH) 1, (YEAR). The plan shall include a schedule to conduct routine Legionella culture sampling and analysis at intervals not to exceed 90 days in the first year and annually thereafter. 415.19(a)(1) 10 NYCRR Subpart 4-2.4

Plan of Correction: ApprovedDecember 12, 2018

In order to be in compliance with part 4 of the NYS Sanitary Code the facility did the following. The CEO, Administrator, and Plant Maintenance Supervisor conferenced with members of the WNY Dept. of Health to discuss the requirements for Legionella Testing. Members of the facility Safety Committee developed a Water Sampling Management Plan and contracted with an outside lab to do testing of the facility potable water system. The facility will begin sending samples per the management plan to the lab every 90 days for Legionella testing for the first year annually after that. Maintenance staff will be educated by the laboratory for proper sample collection prior to the first samples being submitted. The facility anticipates the first samples to be sent out for testing no later than 1/14/19. Results of the sample testing will be reviewed at the facility's monthly Safety Committee Meetings.
Person responsible: Maintenance Supervisor

FF11 483.75(g)(2)(ii):QAPI/QAA IMPROVEMENT ACTIVITIES

REGULATION: §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview statements conducted during the Standard survey completed on 11/16/18, the facility did not ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed and acted on available data to make improvements. Specifically, the QAA committee did not ensure that the approved Plan of Correction (P(NAME)) for F329 - Drug Regimen is Free from Unnecessary Drugs, cited during the Standard survey completed on 6/9/17 was implemented. The findings are: Refer to F 758- Unnecessary [MEDICAL CONDITION] Drug Use - Scope and Severity E. 1.) Review of the approved Plan of Correction (P(NAME)) for the Standard survey completed on 6/9/17 revealed the facility identified a correction date of 8/4/17 related to the deficient practices cited under F329 - Drug Regimen is Free from Unnecessary Drugs. The following corrective actions were identified: The DON or designee will audit all residents with routine and PRN (as needed) antipsychotic medications each month to ensure proper initiation, interventions, and documented continued evidence of behaviors to support the use of the medication. This will include review of behavior monitor logs, nurses' notes, and comprehensive care plans. The DON will report the findings of this audit monthly to the Quality Assurance (QA) Committee. The QA Committee will ensure the corrective action is maintained by determining there is a decrease in utilization of psychoactive medications and increased effectiveness of documented interventions. This process will be ongoing. The person responsible for compliance was the Director of Nursing and the alleged completion date was 8/4/17. A Psychoactive and Sedative/Hypnotic Utilization Trends Report for data compiled on 6/14/17 documented an audit for psychoactive drug use between 6/1/17 and 6/14/17 revealed a facility Psychoactive Utilization rate of 69.1%. No additional reports were formulated by the facility per the Administrator. During an interview on 11/16/18 at 12:36 PM, the Administrator stated that the full QAA committee meets quarterly. Antipsychotic reviews are done by the behavioral committee team which consist of the Director of Nursing (DON), Social Worker, MDS (Minimum Data Set) Coordinator, Pharmacy Consultant and the Administrator. The Administrator stated that the antipsychotic rate is not coming down as planned and there is room for improvement in the behavioral documentation. The facility relies on the Consultant Pharmacist's monthly drug regiment reviews to assist the facility with the proper utilization of antipsychotic medications and he (the Consultant Pharmacist) did verbally inform the staff regarding the new regulation for the 14-day limitation for the PRN psychoactive medication orders; however, he did not know if the pharmacist was documenting this during the routine monthly drug regimen reviews. The Administrator stated that the behavioral committee meetings are an adjunct/ concurrent audit of the facility's use of the antipsychotic medications. During an additional interview on 11/16/18 at 12:50 PM, the Administrator stated he could not provide copies of the monthly reports on psychoactive medications from 7/2017 to current. The Administrator stated he recognized an issue with psychoactive medication use in (MONTH) (YEAR). 415.27(c)(3)(iv,v)

Plan of Correction: ApprovedDecember 17, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In order to be compliant with 483.75(g)(2)(ii) QAPI/QAA Improvement Activities the facility will do the following. All orders for [MEDICAL CONDITION] drugs will be inventoried using the facility [MEDICAL CONDITION] Medication Tracking Tool. The tool was developed by the Administrator in conjunction with a state healthcare association. All [MEDICAL CONDITION] medications will be addressed on the form initially by the Director of Nursing in conjunction with members of the care planning team. Subsequently all new orders for [MEDICAL CONDITION] medications will have the form initiated at the time of the order for review by the care planning team at morning report. The form will become part of the residents comprehensive care plan and be reviewed at least quarterly at the CCP Meetings. additionally all [MEDICAL CONDITION] drugs will be reviewed at the monthly Behavioral Review meeting. The [MEDICAL CONDITION] Medication Tracking form addresses the diagnosis, targeted behavior, possible underlying causes of behavior, non-pharmacological interventions, risk/benefit consent of resident/legal representative for the specific med, documentation of the most recent GDR with outcome or if GDR deemed not appropriate physician documentation for maintaining current dose. All Members of the care planning team will be educated on the use of the form by the RN Education Coordinator.
All [MEDICAL CONDITION] Medications will be addressed at the facility Monthly Behavioral Meeting whose members include the Social Worker, Director of Nursing, Pharmacy Consultant, and Unit Manager. The committee will ensure the [MEDICAL CONDITION] Medication Tracking Tools are up to date and that the facility is in compliance with CMS regulations regarding unnecessary drugs.
The committee will report its activities to the facility's regularly scheduled QAPI Meeting for review with the ultimate goal of eliminating any unnecessary medications.

Person Responsible: Director of Nursing

FF11 483.10(c)(6)(8)(g)(12)(i)-(v):REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR

REGULATION: §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard Survey completed on [DATE], the facility did not ensure the system developed for Advance Directives was implemented in a manner that was consistent with resident's wishes. Ten (Resident's #25, 31, 38, 40, 47, 48, 99, 101, 104, & 249) of 24 residents reviewed for Advance Directives, the facility did not implement the facility's process for identifying the resident's Advance Directive information. The findings are but not limited to: The facility's policy entitled Advance Directives/ Medical Orders for Life Sustaining Treatment (MOLST) documented the facility uses the MOLST form for obtaining orders regarding a resident's preferences for life sustaining treatment. The facility's policy entitled DNR (do not resuscitate) Patient/ Elder Identification revised on ,[DATE] documented that a resident with a DNR status will have a pink/red DNR ID (identification) band placed on them for identification of Do Not Resuscitate. The resident with a Full Code status will have a blue Full Code ID band placed on them for identification of a Full Code. In addition, the resident will have a valid DNR or MOLST form and a physician order. The resident will have a color-coded wrist band that identifies their code status. The facility's policy entitled Cardio-Pulmonary Arrest/ Codes Adult and Pediatric dated ,[DATE] documented the Code Blue term refers to any adult cardiopulmonary arrest situation in the building, including Long Term care (LTC) and the Medical Care Unit will respond with the crash cart to any adult in the building. 1. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident has no cognitive impairment and understands and sometimes is understood. The Comprehensive Care Plan dated [DATE] documented the resident as a DNR/DNI (do not intubate). The MOLST form dated [DATE] documented a DNR Order: Do Not Attempt Resuscitation (Allow Natural Death), signed by the resident on [DATE] at 3:25 PM. During initial screen observations on [DATE] at 10:05 AM, Resident #40 was self-propelling himself on Unit 3 and wearing a wrist band that was blue signifying Full Code. During an interview on [DATE] at 2:59 PM, Certified Nurse Aide (CNA) #4 stated that it is a requirement to get CPR (cardio-pulmonary resuscitation) certified and initiate CPR immediately upon finding an unresponsive resident, after calling out for help. She stated that a red wrist band meant DNR, and a blue wrist band meant Full Code. During an interview on [DATE] at 3:32 PM, the Director of Nursing (DON) stated when a [MEDICAL CONDITION] happens, staff dial 911 and the Response Team comes from the Hospital Urgent Care on the first floor and the nurse brings a crash cart. The Unit Secretary is responsible to place the wrist band on the resident upon admission. The wrist band should indicate if the resident's status is a Code (blue) or DNR (red). During an interview on [DATE] at 9:57 AM, the Social Worker (SW) stated that upon admission if the resident does not have an Advance Directive in place, she gives the resident and/ or the family the Advance Directive paper work to fill out and assists if needed. The interdisciplinary team meets to discuss the resident's needs and wishes and the SW formulates the Advance Directive care plan. The nurse is responsible to document the Code status on the CNA Pocket Care Plan. During an interview on [DATE] at 10:14 AM, the Registered Nurse (RN) #3 Unit Manager stated that the Unit Secretary is responsible to make the wrist bands and either the nurse or the Unit Secretary places the band on the resident. In addition, anyone who takes care of the resident should verify that the wrist band is accurate. 2. Resident #25 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that the resident is moderately cognitively impaired and is understood and understands. Observation on [DATE] revealed the resident was in her room watching television with no wrist band noted on either wrist. During an interview on [DATE] at 10:00 AM, Licensed Practical Nurse (LPN) #2 stated regarding resident wrist bands, Pink means they're a DNR and blue is Full Code. I would also look on the chart binder and the face sheet for what the resident's status is. During an interview on [DATE] at 2:51 PM, LPN #3 stated, I would look at the bracelets with red being a DNR and blue a Full Code. I could also look at the chart binder. The computer also has it right on the top of the screen of what the resident's status is. During an interview on [DATE] at 2:57 PM, CNA #5 stated, I would look at the bracelet on the resident's wrist. DNR is red and Full Code is blue. If there was no band I would look on the computer under the ADL (activity of daily living) as what kind of status is listed there. 3. Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was with moderate cognitive impairment and understands and is understood. physician's orders [REDACTED]. Observations on [DATE] at 10:00 AM and 2:50 PM revealed the resident was not wearing a wrist band. During an interview on [DATE] at 2:54 PM, the Activities Aide stated that if a resident became unconscious he would check the resident's wrist band and if the resident was not wearing one he would find a nurse; he was CPR certified and would start CPR if indicated. During an interview on [DATE] at 3:02 PM, CNA #2 stated that she would look at the resident's wristband for the code status; she was CPR certified and would start CPR if indicated. During an interview on [DATE] at 3:03 PM, CNA #3 stated she would look for the resident's wristband for the code status and if that was missing she would look on the CNA Pocket Care Plan; she was CPR certified and should would start CPR if indicated. During an interview on [DATE] at 3:05 PM, RN #3 Unit Manager stated she would look on the MOLST form in the medical record or on the chart binder to find the resident's code status if the resident's wrist band was missing. 415.3 (e)(i)(ii)

Plan of Correction: ApprovedDecember 17, 2018

In order to comply with 483.10 and ensure residents wishes regarding resuscitation are complied with the facility will do the following. Residents 25,31,38,40,47,48,99,101, 104 and 249 were fitted with new id bracelets indicating their code status by the Unit Secretary and RN Unit Manager. All residents in house were examined to ensure id bracelets were present and accurate as to code status. A daily check of all residents will be performed by the RN Unit Manager or designee to ensure id bracelets with the current code status are present. The daily checks will be performed daily for 6 months and continue to be completed 3 times per week thereafter for one year. This will be documented on a Daily Bracelet Check Form that includes all current residents on each floor. In addition, new storage containers will be purchased and available 24 hours per day, 7 days per week to nursing staff to replace or update id bracelets as needed. All SNF staff including RNs, LPNs, and CNAs will be re-educated on the Policy for identifying resident's resuscitation status by the RN Education Coordinator.
The results of the Daily Bracelet Audits will be presented at the facility's regularly scheduled Quality Assurance Committee Meetings.
Person Responsible: Director of Nursing

FF11 483.25(a)(1)(2):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- §483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 11/16/18, the facility did not ensure that residents received proper treatment and assistive devices to maintain vision and hearing abilities. One (Resident #22) of three residents reviewed for vision and hearing assistance, the facility did not act on the ophthalmologist's recommendation to obtain reading glasses for the resident who had visual changes. The finding is: 1. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS- a resident assessment tool) dated 8/23/18 documented the resident was cognitively intact and saw fine and did not have glasses. The Comprehensive Care Plan dated 9/5/18 documented a revision on 10/19/17 for impaired vision and the use of glasses with a goal for the resident to remain safe and participate in social and self-care activities, defined in the resident's care plan on 3/5/18 for preferences that included reading and watching television. The Certified Nursing Aide (CNA) Pocket Care Plan documented the resident wore glasses. During an interview on 11/13/18 at 10:33 AM, the resident who was not wearing glasses, stated, I can't see. I went to the eye doctor and should have new glasses but I haven't gotten them yet. An ophthalmology consult dated 10/9/18 documented the resident had an artificial lens implant right eye - stable, cataract left eye moderate continue to monitor, presbyopia (aging of the eye that results in progressively worsening ability to focus clearly on close objects). Prescription for reading glasses. During an interview on 11/16/18 at 11:00 AM, the Social Worker (SW) stated she was not aware that the resident was having vision problems and that he needed new glasses based on the recent ophthalmology consult. The SW stated she would check with the Unit Secretary since she did all the scheduling for resident appointments. During an interview on 11/16/18 at 11:18 AM, the Unit Secretary stated that she was not given a prescription for the resident to get glasses and no appointment was made to get glasses. During an interview on 11/16/18 at 11:25 AM, the Registered Nurse (RN) #3 Unit Manager, stated she was not aware that the ophthalmologist recommended reading glasses for the resident, and would check into it now. RN #3 stated recommendations for consults should be picked up by the receiving nurse and/ or the Unit Manager and the appointments are scheduled by the Unit Secretary. 415.12 (3)(b)

Plan of Correction: ApprovedDecember 17, 2018

In order to be compliant with 483.25 the facility will ensure all residents receive proper assistive devices to maintain vision abilities by the following. Resident #22's prescription was obtained from the ophthalmologist on 11/29/18 and the prescribed reading glasses will be obtained by 12/14/18. In the interim, non-prescription reading glasses similar to the prescription were obtained for his use on 12/3/18. All residents of the facility were reviewed going back one year to ensure eye exams were completed per regulation and that there were no other outstanding prescriptions for glasses. All SNF staff, including RNs, LPNs, CNAs, and the Unit Secretary will be educated by the RN Education Coordinator.on the procedure for eye examinations. The procedure states all residents will be seen annually by an optometrist or opthamologist for an exam. Any needs arising as a result of the exams, including prescription glasses, will be identified and tracked by the unit secretary on a vision log. The log will show identify each residents current vision status, date of last appointment, and the results of that appointment. A follow up call will then be made by the unit secretary to confirm after each visit whether a prescription was warranted and the expected date of the arrival of the vision aid (glasses).
The facility will conduct a monthly audit including the residents who are due for or have had eye examinations and the results of those eye examinations for 6 Months and then quarterly for the remainder of the year. The results of the monthly audits will be reported at the regularly scheduled facility Quality Assurance Meetings.
Person responsible: Director of Nursing

Standard Life Safety Code Citations

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: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 11/16/18, the facility did not have documentation to verify patient care related electrical equipment (PCREE) had been properly maintained. Issues included the facility did not have a policy for the maintenance of PCREE and did not have documentation that verified mechanical lifts were inspected monthly per the manufacturer's recommendations. This affected two (Second and Third Floors) of three resident use floors. The findings are: 1. During an interview on 11/16/18 at 2:15 PM, the Administrator stated the facility does not have a policy regarding the maintenance of PCREE. 2. Intermittent observations on the Second and Third Floors on 11/14/18 between 11:30 AM and 12:45 PM revealed mechanical lifts were stored in the resident unit corridors. Specifically, a 600-pound capacity mechanical lift was observed in the Second Floor corridor with a white sticker from an outside contractor that stated an inspection of the lift was performed 7/18 and the next inspection was due 7/19. Record review of the manufacturer's User Manual for the 600-pound capacity mechanical lift revealed the following items are to be inspected and/or adjusted monthly: -caster base hardware -caster base open/close mechanism -casters and axle bolts -wheels -shifter handle operation -shifter handle lock -mast and boom attachment point -condition of mast -condition of boom -boom hardware -bolted joints on boom -location of boom -mast pivot bolt -condition of swivel bar bolt and hooks -sling hooks -manual/hydraulic pump/electric [MEDICATION NAME] assembly -operation of pump handle -operation of control valve -condition of slings and sling attachments -cleanliness, clean when necessary During an interview on 11/15/18, the outside contractor for the maintenance of PCREE stated he inspects the facility's lifts on an annual basis and the white sticker indicates the lift passed the inspection. During an interview on 11/14/18 at 12:30 PM, the Maintenance Supervisor stated the outside contractor performs annual inspections of the facility's lifts and the facility's maintenance department does not perform any additional preventative maintenance. During an interview on 11/16/18 at 12:45 PM, a Certified Nurse Aide on the Third Floor stated before using a lift, she checks the battery, checks the motion of the legs and the vertical lift, including testing the emergency brake, and checks the buckles. During an interview on 11/16/18 at 1:05 PM, a Certified Nurse Aide on the Second Floor stated before using a lift, she checks the buckles, checks the battery, and checks the condition of the sling. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.5.2.1.1, 10.5.3.1.2, 10.5.6.2.1

Plan of Correction: ApprovedDecember 20, 2018

In order to comply with NFPA 101 Electrical Equipment - Testing and Maintenance the facility will do the following. The manufacturers specifications were obtained for preventative maintenance on each of the three mechanical lifts in use. Based on their recommendations each lift will be inspected monthly by a member of the maintenance department and recorded on a mechanical lift PM sheet. This will be in addition to the annual inspections and repairs currently in place being conducted by an outside vendor. The results of the inspections will be reported to the monthly safety committee for review.
Person Responsible: Maintenance Supervisor

EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on [DATE], it was determined that the facility did not comply with emergency preparedness requirements. Specifically, three of four employees interviewed for knowledge of emergency procedures lacked basic knowledge of the emergency procedures. The findings are: 1. During an interview on [DATE] at 10:20 AM, the Chief Clinical Officer stated all staff have been trained on emergency preparedness. Additionally, on [DATE] at 11:08 AM, the Education Manager stated each employee receives emergency preparedness training at General Orientation and then annually each January. 2. Interviews with randomly-chosen employees, regarding their knowledge of emergency procedures, on [DATE] from 12:30 PM until 1:05 PM revealed the following: - Hospitality Aide stated she has worked in this facility for eight years and recalled an outdoor decontamination training done a few years ago, but could not recall any training around (MONTH) (YEAR) that covered the topics of fire or emergencies. - Certified Nurse Aide (CNA) A stated she was hired at this facility in (MONTH) (YEAR) and could not recall if the topic of emergency preparedness was discussed at General Orientation. She added that some of the emergency codes are colors, but could not give any examples because she did not have her identification badge with her at this time. When asked for the code phrase for activation of the emergency plan, she stated she did not know. - CNA B stated he has worked in this facility for three and a half years and he attended a Cardiopulmonary Resuscitation (CPR) training and received information about tornadoes during an actual tornado warning. At this time, he referred to his identification badge and stated that the facility uses Code Red and Code Blue. When asked if he had heard of the Hospital Incident Command System (HICS), he replied that he had not, and did not know the code phrase for the activation of the emergency plan. Record review on [DATE] and [DATE] of the facility's Comprehensive Emergency Management Plan (CEMP), revised [DATE], revealed HICS is discussed throughout the plan, and Code HICS is used to announce that the emergency plan has been activated. Record review of the training records for the chosen employees revealed the Hospitality Aide attended annual training on [DATE], CNA A attended General Orientation on [DATE], and CNA B attended annual training on [DATE]. During an interview on [DATE] at 1:57 PM, the Education Manager stated she would expect each CNA to have heard of HICS and to know that Code HICS is used to activate the emergency plan, and only upper management would need to have a thorough understanding of how HICS works. Per Centers for Medicare and Medicaid Services (CMS), Long Term Care facilities must do all of the following: I. Provide initial training in Emergency Preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. II. Provide emergency preparedness training at least annually. III. Maintain documentation of the training. IV. Demonstrate staff knowledge of emergency procedures. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(d)(1)

Plan of Correction: ApprovedDecember 20, 2018

To ensure compliance with 491.12 the facility will do the following. All SNF staff will participate in a mandatory education session covering the Comprehensive Emergency Management Plan with testing to ensure retention by 1/31/19. The CEMP education will be mandatory for all new staff as well as an annual mandatory inservice for existing staff. The Education Coordinator will report the education dates and results to the facility Quality Assurance/Performance Committee monthly for review.
Person responsible: Education Coordinator

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 11/16/18, the facility did not ensure that a formal and documented risk assessment for the building system categories was conducted in accordance with National Fire Protection Association (NFPA) 99 - Health Care Facilities Code. This affected three (First, Second, and Third) of three resident use floors. The finding is: 1. Record review of the facility's preventative maintenance and emergency preparedness documents on 11/13/18 through 11/16/18 revealed no formal and documented risk assessment for the building system categories in accordance with the 2012 edition of NFPA 99 - Health Care Facilities Code. During an interview on 11/16/18 at 2:40 PM, the Maintenance Supervisor stated the facility does not have a completed NFPA 99 Risk Assessment. Per the 2012 edition of NFPA 99, building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code and the categories shall be determined by following and documenting a defined risk assessment procedure. 10NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 4.1, 4.2, 4.3

Plan of Correction: ApprovedDecember 20, 2018

In order to be in compliance with NFPA 101 Fundamentals - Building System Categories the facility will conduct a safety committee meeting specifically for the purposes of educating the members of the committee and completing the NFPA 99. The results of the NFPA 99 Risk assessment will be integrated into the facility Emergency Preparedness Plan which is reviewed annually.
Person Responsible; Administrator

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 11/16/18, signage stating that oxygen was stored within a room was not present. This affected two (Second and Third Floors) of three resident use floors. The findings are: 1. Observation on the Third Floor on 11/13/18 at 9:42 AM revealed three E sized oxygen cylinders were stored in carts in the Storage Room across from the Nurses' Station. Continued observation on the corridor side of the room revealed there was no precautionary sign that stated CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING. During an interview at the time of the observation, a Certified Nurse Aide stated this Storage Room is where oxygen cylinders are always stored. At this time, the Maintenance Supervisor stated a few months ago, the facility started storing oxygen cylinders in this room instead of at the Nurses ' Station. 2. Observation on the Second Floor on 11/13/18 at 10:10 AM revealed eight E sized oxygen cylinders were stored in carts in the Office outside of the Common Area. Continued observation on the corridor side of the room revealed there was no precautionary sign that stated CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING. During an interview at the time of the observation, the Maintenance Supervisor stated this office was converted to an oxygen storage room a few months ago. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.3.2.4 2012 NFPA 99: 11.3.4, 11.3.4.1, 11.3.4.2

Plan of Correction: ApprovedDecember 20, 2018

In order to be in compliance with NFPA 101 Gas Equipment - Cylinder and Container Storage the facility did the following. The converted oxygen storage rooms on third and second floors were labeled with precautionary signs stating CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING. All staff will be educated on the proper storage and risks associated with oxygen storage. This education will be mandatory for all new employees and provided annually for all staff to ensure compliance. The education dates and times and subsequent testing results will be reported to the facility Monthly Safety Committee. Additionally, daily oxygen storage room checks will be conducted by maintenance personnel. Once per shift oxygen room storage audits will be performed by charge nurse additionally for 6 months then daily after that. Results of audits will be presented at monthly Safety Committee Meetings.
Person Responsible: Education Coordinator


K307 NFPA 101:GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG

REGULATION: Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 11/16/18, oxygen cylinders were not properly restrained. This affected one (Second Floor) of three resident use floors. The finding is: 1. Observation on the Second Floor on 11/13/18 at 10:15 AM revealed one D sized oxygen cylinder, in a nylon carrying case, was free-standing and unsecured on the floor of the Nurses' Station. During an interview at the time of the observation, a member of the Nursing Staff stated the oxygen cylinder had been stored in this location for about one week. Also at this time, the Maintenance Supervisor stated the cylinder should be secured in a stand or a cart. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.3.2.4 2012 NFPA 99: 11.6.2, 11.6.2.3, 11.6.2.3(1), 11.6.2.3(11)

Plan of Correction: ApprovedDecember 20, 2018

In order to be in compliance with NFPA 101 Gas Equipment - Precautions for Handling Oxygen the facility removed the D sized oxygen tank from the floor of the nurses station and properly secured it until it could be returned. All staff will be re-educated on the proper storage of oxygen tanks and the training will become an annual, mandatory training for all staff. In addition, maintenance personnel will conduct daily Oxygen Storage checks to make sure all oxygen tanks are properly secured. The results of the daily Oxygen Storage checks will be reported to the monthly Safety Committee along with the education and testing dates for review.
Person Responsible: Maintenance Supervisor

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 11/16/18, rooms identified as hazardous areas were not protected. Issues included, doors that protected hazardous areas did not self-close and latch into their door frames. This affected one (Second Floor) of three resident use floors and the Ground Floor. The findings are: 1. Observation on the Second Floor on 11/13/18 at 9:55 AM revealed the door to the Clean Utility Room would not self-close and latch into its door frame. During an interview at the time of the observation, the Maintenance Supervisor stated the handle to this door needed to be tightened. 2. Observation on the Second Floor on 11/13/18 at 9:58 AM revealed one (the door closest to Resident room [ROOM NUMBER]) of two doors to the Soiled Utility Room would not self-close and latch into its door frame. During an interview at the time of the observation, the Maintenance Supervisor stated the handle to this door needed to be tightened. 3. Observation on the Second Floor on 11/13/18 at 10:05 AM revealed the door to the Clean Linen Room would not self-close and latch into its door frame. During an interview at the time of the observation, the Maintenance Supervisor stated the door closing mechanism needed to be sped up. 4. Observation on the Ground Floor on 11/13/18 at 11:15 AM revealed the side door to the Kitchen (near dishwashing machine) would not self-close and latch into its door frame. During an interview at the time of the observation, the Maintenance Supervisor stated this door has been identified as an ongoing problem, and a replacement door had been ordered. 5. Observation on the Ground Floor on 11/13/18 at 11:20 AM revealed the door to the Maintenance Storage Room would not self-close and latch into its door frame. During an interview at the time of the observation, the Maintenance Supervisor stated this door's handle and latch needed to be oiled. During an interview on 11/16/18 at 3:10 PM, the Maintenance Supervisor stated the facility maintenance department checks all doors on both of the Skilled Nursing Facility's units and a random sampling of doors on the First Floor on a weekly basis. Record review of the weekly door check log revealed the checks were last performed on 11/8/18 and all doors were satisfactory at that time. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2, 19.3.2.1.3, 19.3.2.1.5

Plan of Correction: ApprovedDecember 20, 2018

In order to comply with NFPA 101 the facility did the following. The second floor clean utility room. second floor soiled utility room door, second floor clean utility room door,and maintenance storage room doors were repaired to self close. The dishroom door and closer had been ordered prior to survey and is scheduled to be installed during the month of December. A complete audit of all hazardous doors will be completed to ensure each one properly closes and latches.
All hazardous storage area doors will be inspected weekly as part of facility preventative maintenance program. The results of the checks will be reported to the monthly Safety Committee Meeting for review.
Person Responsible: Maintenance Supervisor

K307 NFPA 101:HVAC

REGULATION: HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a Life Safety Code survey completed on 11/16/18, mechanical dampers were not maintained. Issues included, mechanical dampers that failed inspection and were not repaired or replaced. This affected one (Third Floor) of three resident use floors. The finding is: 1. Record review on 11/13/18 and 11/14/18 revealed the facility's thirteen smoke dampers and two fire dampers were inspected by an outside contractor on 9/26/17. The inspection report stated five smoke dampers and one fire damper failed the inspection, and their locations were Hall by room [ROOM NUMBER] (1), Hall by room [ROOM NUMBER] (2), Hall by Kitchen, Hall by room [ROOM NUMBER], Kitchen 2, and Office 4. Record review of the inspection test report from the same outside contractor dated 9/21/18 revealed the same five smoke dampers and one fire damper failed the inspection. During an interview on 11/14/18 at 10:15 AM, the Maintenance Supervisor stated the six total dampers that failed the (YEAR) inspection are the same six dampers that failed the (YEAR) inspection, and they are all located on the Third Floor. He further stated the failed dampers have not been repaired or replaced yet. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.5.2.1, 9.2 2012 NFPA 90A: 5.4.8.1, 5.4.8.2 2010 NFPA 80: 19.4, 19.5 2010 NFPA 105: 6.5, 6.6

Plan of Correction: ApprovedDecember 20, 2018

In order to be in compliance with NFPA 101-HVAC the facility had ordered motors to repair the dampers prior to survey. The repairs to the dampers are scheduled to be done by an outside contractor between (MONTH) 15-19th (YEAR). Damper inspections by maintenance staff every 6 months will be added to the facility preventative maintenance program. This will be in addition to the annual inspections done by the outside contractor. The results of the inspections will be reported to the monthly Safety Committee for review.
Person Responsible: Maintenance Supervisor

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID 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.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC 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 annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 16, 2018
Corrected date: December 4, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 11/16/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not have documentation that they shared information from their Emergency Preparedness Plan with residents and their families or representatives. The finding is: 1. Record review on 11/15/18 and 11/16/18 of the facility's Comprehensive Emergency Management Plan (CEMP), revised 3/2/18, and the associated Annexes revealed the facility did not have documentation that they shared information from their Emergency Preparedness Plan with residents and their families or representatives. During an interview on 11/16/18 at 12:04 PM, the Chief Clinical Officer stated she addressed this topic at a Family Council meeting. Record review of Family Council meeting minutes revealed Disaster Plan/ Emergency Preparedness was discussed on 1/31/17 and there were ten signatures on this meeting's sign-in sheet. During a further interview on 11/16/18 at 1:25 PM, the Chief Clinical Officer stated she did not have documentation that the topic of emergency preparedness was discussed with residents or families, in any form of communication, since (MONTH) (YEAR). 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedDecember 7, 2018

In order to be in compliance with E035 of LSC all family members were notified via mail regarding the existence of our facility Emergency Preparedness Plan along with some basic information about what it contains and contact information for further questions. This notification will be mailed each December. A copy of the mailing will be provided to the Safety Committee each Decemeber to demonstrate compliance.
Person responsible: Social Worker

K307 NFPA 101:PROTECTION - OTHER

REGULATION: Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

Based on observation, interview and record review during a Life Safety Code survey completed on 11/16/18, the Clean Agent Fire Extinguishing System in the Information Services Room was not maintained. This affected one (First Floor) of three resident use floors. The finding is: 1. Observation on the First Floor on 11/13/18 at 10:50 AM revealed the Information Services Room was equipped with a Clean Agent Fire Extinguishing System. Further observation revealed a sign on the wall read HFC 227ea Extinguishment System and inspection tags were located on the system's control panel and tank that said an inspection was performed on 8/2/18. Further observation of the Information Services Room revealed the room measured approximately 16 feet long by 12 feet wide, approximately half of the ceiling tiles were absent, and there were two approximately one quarter of an inch diameter holes through the door that separated the Information Services Room from the Information Services Office. Record review of an outside contractor's ten-page inspection report dated 8/17/17 revealed the Clean Agent Extinguishment System had 13 components and all 13 components were listed as passed, and a General Note was written on the report that said, Failed door fan test. Record review of the outside contractor's one-page Service Ticket dated 8/2/18 revealed no information on whether or not the Clean Agent Extinguishment System or its components passed the inspection, and the following was written under Remaining Issues & Actions: Room needs to be sealed, ceiling tiles replaced, door needs sweep and seals. During an interview on 11/13/18 at 10:50 AM, the Maintenance Supervisor stated the Clean Agent Extinguishing System covers only the Information Services Room, and not the attached office. On 11/14/18 at 9:20 AM, the Maintenance Supervisor stated he did not receive a full inspection report from the outside contractor for the 8/2/18 inspection, only a one-page Service Ticket. Additionally, on 11/16/18 at 2:55 PM, the Maintenance Supervisor stated the Information Services Room failed the door fan test performed by the outside contractor on 8/17/17, even though all of the room's ceiling tiles were in place at that time. He added that approximately half of the room's ceiling tiles were removed from the Information Services Room a few months ago, at the request of the facility's Information Technology department. The Maintenance Supervisor also stated the outside contractor will not perform another door fan test until the ceiling tiles are installed and secured in place. Additionally, the Maintenance Supervisor stated the outside contractor was supposed to come back to inspect the Clean Agent System again six months after their inspection on 8/17/17, but never showed up. According to the National Fire Protection Association (NFPA) 2001: Standard on Clean Agent Fire Extinguishing Systems, 2012 edition, at least annually, all systems shall be thoroughly inspected and tested for proper operation by personnel qualified in the installation and testing of clean agent extinguishing systems. This document also states at least semiannually, the agent quantity and pressure of refillable containers shall be checked and at least semiannually, the agent quantity of factory-charged nonrefillable containers that do not have a means of pressure indication shall have the agent quantity checked. This document also states an enclosure protected by the clean agent shall be thoroughly inspected at least every 12 months to determine if penetrations have occurred that could lead to agent leakage, if other changes have occurred that could change the volume of hazard, or both. Where the inspection indicates conditions that could result in the inability of the enclosure to maintain the clean agent concentration, the conditions shall be corrected. Additionally, NFPA 2001 states any penetrations made through the enclosure protected by the clean agent shall be sealed immediately. The method of sealing shall restore the original fire resistance rating of the enclosure. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5.5, 2.2 2012 NFPA 2001: 7.1, 7.1.1, 7.1.3, 7.1.5, 7.4, 7.5

Plan of Correction: ApprovedDecember 20, 2018

In order to be in compliance with NFPA 101-Other the facility will do the following. Upon completion of the air conditioning system installation in the Information Services Room the room will be air sealed using spray foam coated with thermal barrier paint by an outside contractor. This procedure will ensure that the Information Services Room passes the door fan test.
Additionally, the outside inspection contractor will provide the facility with dates for the bi-annual Clean Agent Extinguisher System inspections. The Maintenance Supervisor or his designee will accompany the inspector upon arrival and note any concerns requiring attention. The results of the bi-annual testing will be presented at the monthly Safety Committee meeting for review.
Person Responsible: Maintenance Supervisor

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: November 16, 2018
Corrected date: January 14, 2019

Citation Details

Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on 11/16/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the emergency preparedness plan did not address the facility's role under a waiver declared by the Secretary in accordance with section 1135 of the Act. The finding is: 1. Per Centers for Medicare and Medicaid Services (CMS) The Emergency Preparedness Rule requires that some providers have policies and procedures, which address 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. This may include policies and procedures on what a facility would do if they had to provide care at an approved alternate site as well as processes on how would they let the community know they are operating at a different care site and any reporting they may need to do if they were under an approved 1135 Waiver. Record review on 11/15/18 and 11/16/18 of the facility's Comprehensive Emergency Management Plan (CEMP), revised 3/2/18, and the associated Annexes revealed information on the facility's role under a waiver declared by the Secretary in accordance with section 1135 of the Act was not addressed. Further review of the CEMP revealed the possibility of using an alternate care site was discussed, but information specific to the 1135 Waiver was not included. During an interview on 11/16/18 at 11:54 AM, the Chief Clinical Officer stated she was familiar with the 1135 Waiver, but the facility's written plan does not include general information about it or a process for how to obtain one in an emergency. 10 NYCRR: 400.10(d) 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedDecember 20, 2018

In order to comply with CMS Emergency Preparedness Rules the facility enacted a policy regarding the facilities role under a 1135 waiver. This policy was integrated into the facility Emergency Preparedness Plan. An initial re-education will be conducted with all SNF staff on emergency preparedness that will include the 1135 waiver policy. All staff will receive education on the CEMP policies, including the 1135 Waiver policies, as part of it's annual, mandatory Emergency Preparedness Training. The effectiveness of the training will be evaluated by reviewing the results of the post education quiz which will be presented at the Monthly Safety Committee Meeting for review.
Person responsible: Education Coordinator

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2018
Corrected date: January 14, 2019

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 11/16/18, smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30-minute fire resistance rating, and were not designed to resist the passage of smoke. This affected two (Second and Third Floors) of three resident use floors. The findings are: 1. Observation above the ceiling tiles on the Third Floor on 11/15/18 at 11:40 AM revealed an open penetration through the smoke barrier wall in the corridor outside of Resident Room 307. Further observation revealed the penetration measured approximately two inches wide by two inches high and had three white wires and three blue wires going through it. During an interview at the time of the observation, the Maintenance Supervisor stated new cable was installed a few months ago by outside contractors and fire caulk appeared to have fallen off in this area. 2. Observation above the ceiling tiles on the Third Floor on 11/15/18 at 11:43 AM revealed a penetration, approximately two inches wide by two inches high, through the smoke barrier wall in the corridor outside of Resident Room 309. Additional observation revealed this penetration through the smoke barrier was filled with orange expanding foam. During an interview at the time of the observation, the Maintenance Supervisor stated the facility has not used the expanding foam in a long time, and he believes an outside contractor applied it on the smoke barrier, and he believed it had a fire rating, but he did not know the manufacturer of the product and did not have the manufacturer's specifications for proper use of the product. 3. Observation above the ceiling tiles on the Second Floor on 11/15/18 at 12:20 PM revealed an open penetration through the smoke barrier wall in the corridor across from Resident Room 232. Further observation revealed the penetration had a diameter of approximately two inches and had seven white wires going through it and was observed on both sides of the smoke barrier wall. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.7, 19.3.7.3, 8.5, 8.5.1, 8.5.2, 8.5.2.1, 8.5.2.2

Plan of Correction: ApprovedDecember 21, 2018

In order to comply with NFPA the smoke barrier penetrations identified outside of room 307, outside of room 309, and in the corridor across from room 232 were properly sealed during survey. To ensure no future penetrations in the smoke barrier walls occur the facility will send out notifications to all vendors likely to puncture the barrier walls advising them that they may not do so unless under the supervision of a maintenance employee. Additionally, monthly inspections of the smoke barrier walls will be conducted by maintenance and recorded. The results of these inspections will be reported to the Monthly Safety Committee for review.
Person responsible: Maintenance Supervisor
Directed Plan of Correction
Life Safety Code K372
Members of QA Committee met on 12/21.18 at 10am to develop Directed P(NAME).
Causative Factors:
1. TV Cable installer made several penetrations in smoke barrier walls and failed to properly caulk 2 of the penetrations.
2. Maintenance was aware of the cable installation but failed to go behind the installer after job completion.
3. Maintenance staff was assured by vendor that the penetrations were caulked properly but did not visually confirm.
4. Outside vendors who run cable and wire may not understand the safety issue they impose when leaving a smoke barrier penetration unsealed with fire rated material.
Interventions
1. Policy on smoke penetration inspections and proper smoke penetration sealing was updated. Policy now reflects requirements for outside vendor supervision and discussion with maintenance supervisor regarding details of project. All maintenance personnel were educated on the updated policy. The updated policy will be discussed at the next facility Safety Committee Meeting to ensure other, non maintenance staff is aware of the policy.
2. Letter to outside contractors was sent. The letter detailed the procedure for checking in with maintenance personnel prior to doing any work and the need to be supervised while working to ensure penetrations are properly sealed.
3. A 100% audit of all smoke barrier walls was conducted on 12/15/18 and no further issues with unsealed penetrations were discovered.
4. Monthly checks of all smoke barrier walls will continue and recorded on the Monthly Fire Barrier and Penetrations Routine form.
5. Signs will be posted at the main entrance and maintenance entrance informing outside contractors to meet with maintenance personnel prior to doing any work.
6. Results of the Monthly Fire Barrier and Penetrations Routine form will be reviewed at the monthly Safety Committee Meeting.
Measurements:
-Zero unsealed smoke barrier penetrations
Triggers:
-New outside vendor work
-Inspection results on Monthly Fire Barrier and Penetrations Form