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K0921
D

Outdated Certification of Oxygen Concentrator

Winter Haven, Florida Survey Completed on 02-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain patient care related electrical equipment (PCREE) in accordance with NFPA 99 standards. During a facility tour, it was observed that an oxygen concentrator in the rehabilitation area had an outdated PCREE certification, with the last certification dated July 2021. This indicates that the equipment had not been tested or certified for compliance for a significant period, contrary to the requirements that all PCREE be tested before being put into service and after any repair or modification. The maintenance director, who was present during the tour, acknowledged that the concentrator was provided by a rental company. This suggests a lapse in the facility's oversight of equipment maintenance and certification, particularly for equipment sourced externally. The findings were discussed with the maintenance director and the administrator during the exit conference, highlighting the facility's failure to adhere to established protocols for electrical equipment testing and maintenance.

Plan Of Correction

1. Identified concentrator was removed from service, PCREE certification service completed. 2. Maintenance Director/Designee completed observation of other facility concentrators to verify PCREE certification is completed as required. 3. The administrator provided education for current facility Maintenance Department regarding PCREE maintenance requirements. 4. Maintenance Director/Designee to complete monthly observation of facility concentrators to ensure PCREE certification is completed as required. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.

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