Failure to Implement Carbon Monoxide Alarm Protocols
Penalty
Summary
The facility was found deficient in maintaining carbon monoxide alarms as per the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act. During a documentation review, it was discovered that the facility did not have a written and implemented Evacuation and Alarm Protocols policy for the carbon monoxide detectors/alarms. This deficiency was confirmed through an interview with the Interim Facility Administrator and the Plant Operations Manager, who acknowledged the absence of the necessary policy, affecting the entire facility.
Plan Of Correction
1. There were no negative outcomes due to not having an Evacuation and Alarm Protocol policy in place. 2. The facility will write and implement an Evacuation and Alarm Protocol policy for the Carbon Monoxide detectors/alarms. 3. The policy will be reviewed by facility leadership and approved by the facility QAPI committee.