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NY State Tag
E

Medical Gas and Vacuum System Deficiency

Morrisville, New York Survey Completed on 01-10-2025

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

The facility failed to ensure that the medical gas and vacuum system was inspected and maintained according to the National Fire Protection Association (NFPA) 99: Health Care Facilities code. The annual inspection report dated 2/1/2024 identified deficiencies in the vacuum source system, including inadequate electrical controls, missing hour meters, and the absence of a lag alarm. During an interview on 1/10/2025, the Maintenance Director admitted to being unaware of these deficiencies, as they were not informed by the third-party vendor responsible for the inspection. Additionally, an observation on the same day revealed that the basement medical gas system lacked labeling to indicate it had failed the annual testing.

Plan Of Correction

Plan of Correction: Approved March 5, 2025 The vacuum system will be decommissioned on 2/20/2025. Additional portable suction devices were ordered and received. All staff have been educated on the decommissioning of the previous vacuum system and the implementation of the portable suction machines to be used in its place. The Director of Environmental Services will monitor all vendor reports to ensure no repairs are recommended in the notes of any section and complete an audit, with a 100% threshold, to report to the Quality Assurance Committee quarterly.

See complete original report
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