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NY State Tag
E

Missing Service Manuals and Testing Procedures for PCREE

Rye, New York Survey Completed on 02-20-2025

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 was found to be deficient in ensuring the availability of service manuals for patient care-related electrical equipment (PCREE) during a Life Safety Code survey. Specifically, the service manuals for air mattress pumps (Span, IPS Signa Relief, and Direct Supply), oxygen concentrators (Invacare Platinum XL), and nebulizers (McKesson) were missing and not provided at the time of the survey. These pieces of equipment were noted to be in use during the survey, indicating a lack of compliance with the 2012 NFPA 99 Health Care Facilities Code, which requires that such documentation be available. Additionally, the facility did not have a policy and procedure for testing the patient care-related electrical equipment readily available. During an interview, the Director of Facilities acknowledged that the service manuals were supposed to be provided by central supply and mentioned that a policy and procedure for the frequency of testing the equipment would be provided. This lack of documentation and procedural guidance represents a failure to adhere to the required standards for equipment maintenance and testing.

Plan Of Correction

Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Facilities will secure service manuals for noted patient care related electrical equipment by 3/18/25. - Clinical Educator or designee will review and update the Patient Care Related Electrical Equipment Policy by 4/15/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Beginning on 5/1/25, the Clinical Educator or designee will audit 5 patient care related electrical devices per month x12 months. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Clinical Educator

See complete original report
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