Failure to Obtain Plan Approval for Emergency Power Generator Alterations
Penalty
Summary
The facility failed to obtain the required Pennsylvania Department of Health plan approval for changes to its emergency power generator system, affecting the entire facility. This deficiency was identified through observation, interview, and documentation review conducted on November 14, 2024. The facility initiated alterations to the emergency power generator system without securing the necessary plan approval from the Department of Health, as confirmed during an exit conference with the Director of Nursing and the Maintenance Director. A follow-up onsite revisit on January 8, 2025, confirmed that the facility had still not obtained the required plan approval for the alterations to the emergency power generator system. This was verified during an exit conference with the Administrator and Maintenance Director, indicating that the deficiency remained unaddressed.
Plan Of Correction
Facility currently working with company Holstein and white to get plans submitted. Plans were submitted on 12/5/2024. Tracking number #47765. To prevent reoccurrence, NHA educated environmental service director on the importance of collaborating with the corporate team to make sure correct procedures are followed. NHA or Designee will check in with engineer company 1x monthly for an update on the submitted plans. All trends are brought to QAPI for further action.