Deficiencies in Life Safety Documentation and Carbon Monoxide Alarm Compliance
Penalty
Summary
Surveyors identified several deficiencies related to the facility's compliance with Life Safety Code (LSC) and state regulations. During document review and interviews, it was found that the facility's life safety drawings were incomplete, lacking critical information such as resident room capacities, door swings, fire wall and smoke wall boundaries, hazardous areas, and compartment designations. This was confirmed by the Administrator and Maintenance Director during the exit conference. Additionally, the facility did not have documentation of annual testing and inspection of installed carbon monoxide alarms as required by the manufacturer's instructions and the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. There was also no documentation confirming that the carbon monoxide alarms could be heard by on-duty staff or verifying evacuation and alarm protocols related to these alarms. These deficiencies were acknowledged by facility leadership during interviews.
Plan Of Correction
1. The facility Life Safety drawings will be revised to include the items noted lacking in the survey process. Documentation of annual testing and inspection of installed Carbon Monoxide alarms, per manufacturer's instructions, will also be maintained. The Carbon Monoxide alarms will be modified to ensure they can be heard by on-duty staff as required. Evacuation and alarm protocols will be updated and reviewed at least annually, with annual in-service education for facility staff. 2. The Life Safety drawings will be reviewed for compliance with the required components by the Maintenance Director and NHA. The documentation of annual testing and inspection of Carbon Monoxide alarms will also be reviewed monthly by the Maintenance Director, and documentation of the Carbon Monoxide alarms being able to be heard by on-duty staff will occur monthly. Evacuation and alarm protocols will be reviewed and updated as required, and staff in-services will be held with facility staff to educate on same. Each of these items will be reported monthly to the QAPI Committee for three months, and at least quarterly thereafter until compliance is achieved. Date of correction is 7/30/2025.