Failure to Document Risk Assessment for Building Systems
Penalty
Summary
The facility failed to conduct and document a formal risk assessment for building system categories as required by the 2012 NFPA 99 Health Care Facilities Code. This deficiency was identified during a survey conducted on the 24th of the month in 2025. The surveyors reviewed the documentation provided by the facility and found that it did not include a risk assessment for building system categories, which is necessary to determine the appropriate category for each system based on the potential impact of system failure on patient care. During the exit interview, both the Administrator and the Director of Building Services acknowledged the absence of the required documentation. The facility was unable to provide the necessary risk assessment documentation by the end of the survey, which is a violation of the NFPA 99 code and the New York Codes, Rules, and Regulations (10 NYCRR 711.2 (a)). This oversight indicates a failure to comply with the standards set for ensuring the safety and well-being of patients and caregivers in the event of a building system failure.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. The facility immediately began to create a risk assessment document. Risk assessment is completed and went into effect on 2/12/25. II. Anyone has the potential to be affected. III. The maintenance department was educated on NFPA 101 fundamentals – building system categories on 2/12/25 by Director of Maintenance. IV. The facility created an audit tool to ensure the risk assessments include all required sections and are completed. Audit will be conducted upon creation to risk assessments and assessed quarterly. V. Responsible party: Director of Maintenance/ Designee.