Non-Compliance with Life Safety Code at Kadima Rehabilitation & Nursing
Penalty
Summary
Kadima Rehabilitation & Nursing at Pottstown was found to be non-compliant with the Life Safety Code requirements during a revisit to a Medicare/Medicaid Recertification Survey. The facility failed to maintain a documented program for testing, cleaning, and replacing batteries in the carbon monoxide alarms. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the carbon monoxide detection system was not being maintained as required. Additionally, the facility lacked an evacuation and alarm protocol policy for the carbon monoxide detection system. This was also confirmed by the Director of Maintenance, who admitted that the facility could not provide an alarm protocol and evacuation plan for carbon monoxide. Furthermore, the exterior doors to the Main Mechanical Room, which houses critical utilities such as the domestic water main, main electrical panel, and generator, were not secured from unauthorized access, leaving these utilities vulnerable. These issues were observed and confirmed during the survey, and subsequent observations determined that the deficiencies related to the carbon monoxide alarms and protocols were not corrected.
Plan Of Correction
1. The facility is unable to retroactively document testing, cleaning, and battery replacement program of the carbon monoxide alarms. 2. Facility-wide audit of carbon monoxide detectors conducted. Carbon monoxide detectors will be installed in places where fossil fuel appliances are in use. 3. Audits will be conducted monthly for twelve months and annually thereafter. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring. 4. An evacuation and alarm protocol policy will be written and enacted. Education will be provided to staff regarding policy. 5. Exterior doors to the Main Mechanical Room have been secured and will remain secured at all times. 6. Audits will be conducted monthly for 12 months. 7. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.