Missing Building Systems Risk Assessment
Penalty
Summary
The facility failed to ensure that a completed formal risk assessment for the building system categories was conducted and documented in accordance with NFPA 99 standards. During a life safety recertification survey, it was discovered that documentation of the facility's risk assessment describing the building system categories was missing and not provided. This deficiency affected all three resident buildings within the facility. An interview with the Director of Plant Operations revealed that the risk assessment was not readily available, and the Director stated that it would be located.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The Administrator met with the multidisciplinary team which included the Director of Nursing, the Director of Physical Therapy and the Director of Maintenance. The team reviewed the risk category definitions in NFPA 99 and completed the annual assessment. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that residents have the potential to be affected by this practice. The worksheet is used to record the risk level for listed systems in a given area. Any changes in systems will generate a review of the worksheet. The worksheet will be reviewed and updated at least annually. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The Administrator reviewed and updated the Facilities Risk Assessment Procedure Policy. Any changes in systems will generate a review of the worksheet. The multidisciplinary team will also conduct an annual review and update the NFPA 99 worksheet. The multidisciplinary team will complete documentation of any findings in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review the monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the results to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted.