Deficiency in Electrical Equipment Maintenance and Documentation
Penalty
Summary
The facility failed to provide policies and procedures for Patient Care Related Electrical Equipment (PCREE) and did not conduct maintenance of electrical equipment or maintain a record log of all required testing, test results, and repairs in accordance with NFPA 99: 2012 Edition. This deficiency was identified during a documentation review conducted over three days, where it was revealed that there was no documentation of PCREE testing, inspection, and maintenance available. The surveyor requested the Maintenance Coordinator and Administrator to provide any PCREE documents, but none were provided. In an interview, it was stated that the facility's electrical equipment is inspected and labeled with a sticker, but there were no comprehensive policies or procedures for maintenance, testing, and inspection of PCREE. Additionally, there were no inspection reports available for the facility's patient care-related electrical equipment. This lack of documentation and established procedures was communicated to the facility representatives during the Life Safety Code exit conference.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The VPPO on 12/24/24 updated Electrical Equipment Testing and Maintenance policy and procedure dated 5/1/24, to include Patient Care Related Electrical Equipment (PCREE). 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated on the policy for the maintenance of electrical equipment, and to tag and log all required testing and results and repairs. The Maintenance Director/designee will conduct routine monthly audits of all electrical equipment per manufacturer specifications for results and repairs. Maintenance will tag all inspected equipment. Findings will be submitted to the Administrator for review. 4. Monitoring corrective action: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.