Non-Compliance with NFPA 101 Exit Discharge Requirements
Penalty
Summary
The facility was found to be non-compliant with the National Fire Protection Association (NFPA) 101, 2012 Edition, Sections 19.2.7 and 7.7, during a recertification survey. Specifically, the exit discharges from three resident units were not maintained as required. The B-Wing west exit discharge was observed to be grass instead of an all-weather surface, which is necessary for safe egress. Additionally, the exit discharges from the A-Wing west exit, B-Wing west exit, C-Wing north exit, and C-Wing south exit were not marked to clearly indicate the direction of egress travel to a public way. During a Life Safety Code Post-Survey Review, it was noted that the facility did not provide evidence of installing an all-weather surface on the B-Wing west exit discharge or implementing the Electronic Plan of Correction. The facility had requested a waiver due to winter weather conditions preventing the completion of the required work. However, the facility did not provide an approved time-limited waiver from the Centers for Medicare & Medicaid Services, and the Electronic Plan of Correction was not fully implemented by the documented Credible Allegation Date.
Plan Of Correction
Plan of Correction: Approved February 18, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The facility has requested a time limited waiver for the installation of a permanent all-weather surface as winter weather conditions will prevent completion at this time. The all-weather surface will be installed on the exit discharge from the B-Wing west exit. The facility began the process of vendor quotes on (MONTH) 13, 2025 and have one thus far. Several other vendors have been contacted to review the scope of work. The facility will continue to obtain quotes through the month of (MONTH) as more providers become available with a vendor decision by (MONTH) 1, 2025. Work will be scheduled for a (MONTH) 9, 2025 start and should be completed within one week from start to finish. Completion date set for no later than (MONTH) 18, 2025. During this period the Administrator will check-in with the Sanitarian the first of each month to update progress on the project. During construction, periodic inspections of all exit discharges to ensure that they are clear at all times as well as staff education on same will be completed by the Maintenance Director and/or Administrator. Until the permanent all-weather surface can be installed, a temporary walkway will be put in place from the B-Wing west exit to the public way. All staff to be in-serviced on fire safety. A copy of the resident safety plan, facility life safety floor plan will be submitted to LTCLCwaiver@heath.ny.gov by (MONTH) 29, 2025. Appropriate evacuation route/discharge signage was ordered and scheduled to be fully installed to mark the direction of egress travel from the four noted areas of exit discharge by (MONTH) 29, 2025. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator and maintenance director completed an audit of all exit discharges to ensure all exit discharges were clearly marked to a public way and all-weather discharge passageway surfaces were intact. No additional areas of concern were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Education will be provided to all maintenance staff on maintaining exit discharges with all-weather surfaces and marking exit discharges to make clear the direction of egress travel to the public way. Appropriate direction of egress signage will be installed for the four noted exits to clearly indicate the direction of egress pathways to the public way by (MONTH) 29, 2025. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The maintenance director or maintenance assistant will audit exit passageways for appropriate signage and all-weather surface integrity weekly for two months and monthly thereafter for four months. The results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee monthly and additional recommendations for interventions and duration of audits will be given as needed. This task has also been added to the weekly environmental rounding schedule. Responsible Party: Director of Maintenance