Deficiencies in Life Safety Drawings and Carbon Monoxide Protocols
Penalty
Summary
The facility failed to meet the minimum standards for operation as required by the Department and other state and local agencies. During a document review and observation, it was found that the facility's portable life safety drawings were incomplete. Specifically, they lacked compartment labeling, resident room capacities, firewall boundaries, smoke wall boundaries, and hazardous areas. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director. Additionally, the facility did not have documentation of annual testing and inspection of installed carbon monoxide detectors, as required by the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. The absence of documentation verifying evacuation and alarm protocols was also noted. These deficiencies were confirmed during an interview with the Administrator and Maintenance Director.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. The portable life safety drawings will be updated with compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, and hazardous areas. Annual inspection of installed carbon monoxide detectors will be tested and inspected. A copy of the annual inspection will be kept in the Life Safety Book. Evacuation and alarm protocols will be put in place in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. A copy of the protocols will be placed in the Emergency Preparedness Plan of the facility and in the Life Safety Book. A carbon monoxide detector is installed in the Boiler/Generator Room within 15 feet of the fuel burning Boiler and Generator. Copies of the life safety drawings will be checked for accuracy and updated accordingly. All carbon monoxide detectors will be identified for inspection. Evacuation and alarm protocols will be reviewed by the Maintenance Director or designee for any needed adjustments. Placement of carbon monoxide detectors will be reviewed to ensure proper placement within 15 feet of fuel burning equipment. The Maintenance Director was re-educated on the need to have accurate portable life safety drawings reflecting compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, and hazardous areas; the need for annual inspection and testing of carbon monoxide detectors; the need for evacuation and alarm protocols regarding carbon monoxide alarms; and the need for carbon monoxide detectors in boiler and generator rooms. The Maintenance Director or designee will review the drawings for any changes monthly for three months. The Maintenance Director or designee will review the documentation of carbon monoxide annual inspection and present at QAPI and ensure annual inspection is available at the time of the Life Safety survey. The Maintenance Director or designee will review alarm and evacuation protocols at QAPI and at least annually. The Maintenance Director or designee will review proper placement of carbon monoxide detectors within 15 feet of fuel burning equipment.