Promenade Rehabilitation and Health Care Center
May 22, 2018 Certification Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 22, 2018
Corrected date: June 8, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during a Recertification survey, the facility did not ensure that the most recent MDS assessment, Section N, accurately reflected the resident's medication regimen. Specifically, the MDS documented that the resident is currently receiving an Antipsychotic medication however, there was no documented evidence that this was an accurate assessment. This was evident for 1 of 5 resident reviewed for Unnecessary Medication out of a resident sample of 58 residents. (Resident # 91). The facility's policy Minimum Data Set (MDS) 3.0 dated (MONTH) (YEAR) documented: all staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the MDS RAI Instruction Manual. The policy did not reference the importance or need for accuracy. The findings are: Resident # 91 is a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented intact cognition and that the resident is prescribed an Antipsychotic medication. The physician's orders [REDACTED]. The Medication Administration Records (MAR) for January, February, March, April, and (MONTH) (YEAR) documented that the resident did not receive an Antipsychotic medication. The facility did not accurately document the resident's medication regimen in Section N Medication on the MDS assessment dated [DATE]. On 05/18/18 at 09:43 AM, the Registered Nurse (RN) MDS Assessor was interviewed and stated that when completing the MDS, a review of the physician's orders [REDACTED]. The RN also stated that the [MEDICATION NAME] is used for his [MEDICAL CONDITION]. It should not be coded as an antipsychotic since the action is really an anti-[MEDICAL CONDITION]. Now I learn that it is not an antipsychotic. Moving forward I will be very careful in coding. On 05/18/18 at 09:52 AM, the supervising MDS Coordinator was interviewed and stated that it was a mistake in coding it. I sign off on her work. I would usually check her work. I missed it too. I explained to her about the medication, we will correct. On 05/18/18 at 10:27 AM, the Psychiatrist was interviewed and stated that [MEDICATION NAME] is used for Mood Disorder in psych. It is not an antipsychotic, it is a mood stabilizer. On 05/22/18 at 11:32 AM, the Medical Director was interviewed and stated that [MEDICATION NAME] is not an antipsychotic. On 05/22/18 at 11:45 AM the Pharmacist Consultant was interviewed and stated that [MEDICATION NAME] is an anticonvulsant and a [MEDICAL CONDITION], mood stabilizer action. It is used to treat [MEDICAL CONDITION] disorder. Not in the classification of an antipsychotic. 415.11 (b)

Plan of Correction: ApprovedMay 28, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F641
I. Immediate Corrections:
Resident # 91
1.The MDS Coordinator who coded section N in the annual MDS received an educational counseling on proper assessment and coding for section N from the MDS Director . A copy of the counseling was filed in the Personnel record and the P(NAME) Book.
2. The MDS Director will complete a correction MDS 3.0 to adequately code section N
3. The resident # 91 continues on [MEDICATION NAME] as per MD orders for Mood Disorder.
II. Identification of Other Residents:
1. The MDS Director received a list of Residents who have MD orders for antipsychotics.
2. This list was used to do a comprehensive review of all past annual MDS data submitted for the last 6 months to ensure that Section N was coded correctly.
3. Any quality issues identified by that review will have correction MDS 3.0 completed if indicated.
III. Systemic Changes:
1.The MDS Director has reviewed the Policy on MDS completion and found same compliant.
2. The MDS Coordinator will re-educate the Nurse MDS Coders as well as licensed Nurses on the completion and coding of the MDS with concentration of Section N .
3.The Lesson Plan will concentrate on the definition of Anti-psychotics, and concentration of the [DIAGNOSES REDACTED].
4. A copy of the Lesson Pan and attendance will be filed for reference and validation.
IV. QA Monitoring:
1. The DNS and MDS Director have developed an audit tool to track the coding of MDS 3.0 documents for accuracy in coding of Section N.
2. Audits will be completed by the MDS Director on all MDS documents completed prior to electronic transmission to ensure that coding is accurate and correct.
3. Any quality issues or errors identified on MDS 3.0 coding will be corrected prior to electronic transmission.
4. Completed audits will be reviewed by the DNS, and presented to the QA Committee monthly for discussion and evaluation.
Responsible Party: MDS Coordinator

Standard Life Safety Code Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 22, 2018
Corrected date: July 24, 2018

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that doors to a hazardous area (soiled utility) were made self closing. This was observed on floors 2 and 6. The Finding are: On (MONTH) 16, (YEAR) at 10:45 AM and 1:00 PM during the recertification survey, it was observed that the soiled utility room doors located on resident floors (2, 6) were not self closing in their frames when tested . In an interview with the Maintenance Director on 5/16/18 at approximately 10:50 AM, he stated that the hinges needed to be adjusted and it will be corrected. 2012 NFPA 101 10NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJune 4, 2018

K321
1. Immediate Corrective Actions
1. The soiled utility room doors located on resident floors (2, 6) were not self closing in their frames when tested had the hinges replaced and were made to be self closing. All other hazardous doors were tested and any repairs required were accomplished.
Completed 5/22/2018
II. Identification of Other residents
1. The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.

2. The Facility maintains a preventive maintenance for all doors and has reviewed all doors. The inspection has ensured that all doors are in compliance with NFPA 80 and NFPA 101.
3. No other doors were found out of compliance.
Completion 5/22/2018
III. Systematic Changes
1. The facility has increased to a monthly inspection of all corridor doors to the preventive maintenance program. This is an increase from the recommended quarterly inspections.

2. All facility staff shall be in serviced on the fire safety precautions of doors and the importance of not utilizing unapproved door hold open devices such as but not limited to door wedges and bypassing latch mechanisms. The in-service shall also cover how to report a problem or broken door.
3. Records of inspections shall be kept and reviewed by the Environmental Services coordinator. The environmental services coordinator shall assign qualified STAFF TO PERFORM the inspections and any required repairs will be done during this time. All unsatisfactory findings shall be reported to the QA committee and shall be addressed immediately during the review.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 22, 2018
Corrected date: July 24, 2018

Citation Details

Based on observation and staff interview, it was determined that the facility failed to ensure the all fire dampers installed in connection with the ventilating system equipment are exercised in accordance with NFPA 90 A, standard for the installation Air -Conditioning and Ventilating systems. This was observed on all floors. The findings include: On (MONTH) 16, (YEAR) between the hours of 10:00 AM and 01:30 PM during the recertification survey, it was observed that the facility had installed fire dampers at the vertical ventilation shaft at the resident floors. In an interview with the Maintenance Director on 05/16/18 at approximately 11:00 AM, he could not confirm the periodic exercising of the fire dampers. Also, no documentation was observed. He further stated that after hurricane Sandy, many of the supply vents were disabled and were no longer functional. 10NYCRR 711.2 (a)(29) 2012 NFPA 101

Plan of Correction: ApprovedJune 4, 2018

K 521
I. Immediate Actions
The Facility Has had the Maintenance Director conduct and confirm the periodic exercising of the fire dampers. documentation has been updated.
completion
II. Identification of Other Residents
The Facility respectfully states that all residents were involved in this deficiency, however no residents were directly affected.
All system vents were affected
III. Systematic changes
1. The facility has developed a policy and procedure for the maintenance of smoke and fire dampers in accordance NFPA 90A and NFPA 101.
2. Staff required to complete testing and service shall be in serviced on the new policy and procedures.
3. Records shall be kept of all ventilation system repairs and inspections
Completion 6/30/18
IV. Q/A Monitoring
1. The Director of Environmental Services will conduct weekly audits over the next 2 months and then monthly to ascertain the effectiveness of the changes implemented.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Environmental Services by

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: May 22, 2018
Corrected date: July 24, 2018

Citation Details

Based on emergency preparedness documentation review and staff interview, the facility did not ensure that its emergency preparedness (EP) program addressed its subsistence needs. Reference is made to the lack of documentation for sewage disposal. The finding is: On (MONTH) 15, (YEAR) between 9:30 am- 1:30 pm during the life safety recertification survey, the EP plan was thoroughly reviewed and the following component was not included: (C) Sewage and waste disposal. There was no documentation provided to address the missing components. On (MONTH) 16, (YEAR) at approximately 2:05 pm, this concern was brought to the attention of the Administrator.

Plan of Correction: ApprovedJune 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E015
I. Immediate Corrective Action
1. In [MEDICATION NAME] with E001, the Administrator has contacted IMS emergency management Consultant, to assist facility in development of an updated subsistence Plan. IMS is under contract with NYC DOH for implementation and development of plans for nursing homes.
2. The Administrator will update the existing subsistence plan to include policy and procedures for regulating and control of sewage and waste for residents, staff and volunteers who remain in facility during an emergency or disaster event.
II. Identification of Other Residents
The Facility respectfully states that all residents were involved in this deficiency, however no residents were directly affected.
III. Systemic Changes
1. The Administrator, in conjunction with the Director of Maintenance, Director of Nursing and Medical Director, reviewed and revised the facility emergency policies and procedures and incorporated the sheltering of resident, staff and volunteers in facility during an emergency into the Comprehensive Emergency Preparedness Plan.
2. The Director of Inservice Education will inservice all facility staff on the facility Emergency Preparedness Plan, including the facility procedures for sheltering of resident, staff and volunteers inside the facility during an emergency.
3. Lesson Plan and Attendance Records will be maintained for reference and validation.
I. QA Monitoring
1. The Administrator, in conjunction with the Director of Maintenance, will conduct Emergency Preparedness Drills and/or Tabletop exercises with facility staff on all shifts, then bi-annually thereafter. Documentation of drill and critiques of staff performance will be maintained in logbook for reference and validation.
2. The Director of Maintenance will review the staff response to Emergency Preparedness Drills and Tabletop exercises, including the tracking if staff component of plan, and present findings to the QA Committee on a monthly basis, for evaluation by the QA Committee.
3. Drill response that reveals negative or incorrect response will be immediately reported to the Administrator and Director of Nursing for further action.