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F0921
D

Failure to Obtain HCAI Authorization for Portable AC Installation

Lancaster, California Survey Completed on 09-05-2025

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 obtain written authorization or approval from the Department of Healthcare Access and Information (HCAI) prior to the use of a portable air-conditioning unit in a resident room. During observations, surveyors noted a portable AC unit operating with its ducting routed through a window, secured with duct tape. Interviews with maintenance staff confirmed that the portable AC was installed at a resident's request and that no permit from HCAI was obtained. The Maintenance Supervisor and Administrator both acknowledged that the HVAC unit was installed temporarily due to hot weather and that they were unaware of the requirement to contact HCAI for approval. The Administrator also stated that he was unfamiliar with HCAI and had not contacted the agency prior to installation. Additionally, the facility did not notify the Department of Licensing/Certification within five days of commencing the alteration, as required. Review of facility policies indicated that portable HVAC systems should only be used during power outages or extreme weather, and that maintenance personnel are to follow established safety regulations. There was no documented evidence that HCAI had approved the temporary use of the portable AC unit, and the facility's actions were not in accordance with state building code requirements for healthcare facilities.

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