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NY State Tag
D

Deficiency in Space Heater Use and Documentation

Buffalo, New York Survey Completed on 02-13-2025

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

During a Life Safety Code survey, a deficiency was identified involving the use of a portable electric space heater in a facility. The heater was found operating in the Health Information Office on the first floor of the rear building. It was plugged into a power strip and producing heat, but there was no documentation to confirm that its heating element did not exceed 212 degrees Fahrenheit, as required by the 2012 edition of the National Fire Protection Association 101: Life Safety Code. The heater was not provided by the facility, and the Medical Records Department Director believed it belonged to a co-worker. Interviews conducted during the survey revealed that the facility did not have a written policy on the use of space heaters. The Maintenance Director stated that electric portable space heaters were allowed in non-resident rooms if the heating element did not exceed the maximum temperature. However, the Assistant Maintenance Director could not find specific information from the manufacturer's manual regarding the heater's maximum temperature. The Administrator mentioned that space heaters were not allowed in resident rooms and could only be used in common areas if monitored by staff. Despite these statements, the lack of documentation and a clear policy led to the deficiency.

Plan Of Correction

Plan of Correction: Approved March 11, 2025 The identified space heater and power strip were removed from the facility. An audit was conducted of all staff offices to ensure no other space heaters were in use. Education was provided to the Director of Maintenance and maintenance staff on the NFPA 101 code regarding space heaters and that the facility does not allow space heaters. All staff with offices will be educated that space heaters are prohibited in the facility. An audit tool was created to ensure staff offices remain free of space heaters by the maintenance director. Five staff offices will be audited weekly x4 then monthly x3. Results will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.

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