Failure to Document NFPA 99 Risk Assessment
Summary
The facility was found deficient during a Life Safety Code recertification survey for failing to conduct and document a required NFPA 99 risk assessment. This assessment is crucial for categorizing facility systems based on the potential impact of their failure on patient and caregiver safety. The surveyors noted that during a record review, a completed NFPA 99 Risk Assessment was not present in the maintenance documentation folders. This deficiency was communicated to the Director of Engineering and the Administrator during the exit conference.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Administrator met with the multidisciplinary team which included the Director of Nursing, the Director of Physical Therapy, and the Director of Maintenance. The team reviewed the risk category definitions in NFPA 99 and completed the annual assessment on 3/5/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The worksheet is used to record the risk level for listed systems in a given area. Any changes in systems will generate a review of the worksheet. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The Administrator reviewed and updated the Facilities Risk Assessment Procedure Policy. Any changes in systems will generate a review of the worksheet. The multidisciplinary team will also conduct an annual review and update the NFPA 99 worksheet. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a monthly basis, for one quarter, the Director of Maintenance or Designee will review the risk assessment to identify any changes. Any outstanding findings will be reported to the administrator. On a quarterly basis, the QAPI committee will review the facility risk assessment. On a quarterly basis, the Director of Maintenance or Designee will report the result of the audits to the QAPI committee. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Penalty
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