Pennsylvania Department of Health
HAMILTON ARMS CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 surveys for this facility. Please select a date to view the survey results.

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HAMILTON ARMS CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on September 17, 2024, at Hamilton Arms Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #080202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 17, 2024, it was determined that Hamilton Arms Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type III, (200), unprotected ordinary structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet minimum standards for carbon monoxide detectors for the operation of a facility, as set forth by the Department and by other State and local agencies, responsible for the health and welfare of residents within the component, affecting the entire component.

Findings include:

1. Review of documention and interview on September 17, 2024, between 10:00 AM and 12:00 PM, revealed the manufacture's documention instructions indicated the carbon monoxide detectors were to be replaced after 6 years. The installation date was October 12, 2016.

Interview with the Administrator and the Maintenance Man on September 17, 2024, at 2:00 PM, confirmed the carbon monoxide detection system was not being maintained.

Plan of Correction - To be completed: 11/05/2024

1. Carbon Monoxide detectors were changed and the sticker on the inside revealed "replace unit by June 2033." The detectors were replaced in June of 2023. All 3 detectors will be replaced by May of 2033 meeting the manufacturers requirement.
2. This requirement will be put into our maintenance tels system for monitoring and will be checked annually.
3. Education will be provided to the maintenance staff on replacing the carbon monoxide detectors before their expiration date.
4. Results of the annual audit tool will be reviewed by the QAPI committee.
5. Date Certain 11-5-24

NFPA 101 STANDARD Building Construction Type and Height:

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component.

Findings include:

1. Observation on September 17, 2024, between 10:00 AM and 2:00 PM, revealed the component is a two-story, Type III (200), unprotected ordinary structure, with a basement, which is fully sprinklered. This facility exceeds the maximum allowable story height for this type of construction.

Interview with the Administrator and the Maintenance Man on September 17, 2024, at 2:00 PM, confirmed the building construction type was not allowed.

Plan of Correction - To be completed: 11/05/2024

1.The Facility requests DSI conduct the FSES survey.

2.The K161 Time Limited Waiver was sent to Shosborne@pa.gov via email.

3.The original letter was sent via mail to the Central office.

NFPA 101 STANDARD Means of Egress - General:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to ensure exit access corridors were maintained, clear and unobstructed, on two of three floors within the component.

Findings include:

1. Observation on September 17, 2024, between 12:35 PM and 1:38 PM, revealed the following obstructed corridors:

a. 1:32 PM, 1st floor, 3 side chairs stored across from Resident Room 150;
b. 1:38 PM, 1st floor, bed side table was stored outside Resident Room 154.

Interview with the Maintenance Man on September 17, 2024, at 1:38 PM, confirmed the egress corridor storage.

Plan of Correction - To be completed: 11/05/2024

1. First floor side chairs across from resident room 150 have been removed along with a bed side table stored outside resident room 154.
2. Education will be provided to nursing on removing chairs when not occupied by residents in the corridor.
3. Weekly audits will occur for 1 month. Audits will be conducted by the Director of Nursing or designee.
4. Results of the audits will be reviewed by the QAPI committee.
5. Date certain 11-5-24

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to ensure the portable suppression system was being inspected, monthly, on one of three floors within the component.

Findings include:

1. Observation on September 17, 2024, at 12:42 PM, revealed the "K" extinguisher was not inspected for the month of May.

Interview with the Maintenance Man on September 17, 2024, at 12:42 PM, confirmed the extinguisher was not inspected for May.

Plan of Correction - To be completed: 11/05/2024

1. The K extinguisher was not inspected for the month of May and we cannot fix that issue. We can only assure that moving forward the K extinguisher gets inspected monthly.
2. The monthly extinguisher inspection will be added to our tels system.
3. Education will be provided to the maintenance staff on the importance and requirement of monthly fire extinguisher inspections for all fire extinguishers.
4. A monthly audit will occur to check that all extinguishers have been inspected. The audit will be conducted by the maintenance director or designee.
5. Results of the monthly audit will be reviewed by the QAPI committee.
6. Date certain is 11-5-24

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain the sprinkler system, affecting the entire component.

Findings include:

1. Review of documentation and interview on September 17, 2024, between 10:00 AM and 12:00 PM, revealed the facility failed the to replace the left hand cap at the Fire Department Connection, as reported by Johnson Controls on April 18, 2024.

Interview with the Maintenance Man on September 17, 2024, at 12:00 PM, confirmed the facility failed to have the cap replaced.

Plan of Correction - To be completed: 11/05/2024

1. The left hand cap at the Fire Department Connection was replaced on 7-24-24.
2. Education will be provided to the maintenance department on the necessity of reading and following up on any issues in inspection reports.
3. Results of inspections will be reviewed by the QAPI committee.
4. Date certain is 11-5-24

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors would properly close and resist the passage of smoke, on one of three floors within the component.

Findings include:

1. Observation on September 17, 2024, between 1:05 PM and 1:40 PM, revealed the doors were hitting the fame and failed to latch, when closed, at the following locations:

2nd floor
a. 1:05 PM, Resident Room 258;
b. 1:15 PM, Nurses' Station Med Room;
c. 1:22 PM, Nurses' Lounge;

1st floor
d. 1:30 PM, Resident Room 153;
e. 1:32 PM, Resident Room 154;
f. 1:40 PM, RN Unit Manager.

Interview with the Maintenance Man on September 17, 2024, at 1:40 PM, confirmed the doors were not closing smoke tight.

2. Observation on September 17, 2024, at 1:10 PM, revealed the door, to the Ice Machine Room by the Main Bath on the 2nd floor, was blocked by an ice cart.

Interview with the Maintenance Man on September 17, 2024, at 1:10 PM, confirmed the door was blocked by an ice cart.

3. Observation on September 17, 2024, between 1:28 PM and 1:30 PM, revealed the doors were dragging on the threshold and failed to latch, when closed, at the following locations:

2nd floor
h. 1:20 PM, Resident Room 254;

1st floor
i. 1:30 PM, Resident Room 156.

Interview with the Maintenance Man on September 17, 2024, at 1:30 PM, revealed the doors were dragging on the threshold.

Plan of Correction - To be completed: 11/05/2024

1. Doors were hitting the frame and failed to latch, when closed, at the following locations:
a. resident room 258, 153, and 154.
b. nurses' station med room on 2nd floor.
c. nurses' lounge on 2nd floor
d. 1st floor RN unit managers office
all doors were repaired.
2. The ice machine room by the main bath on 2nd floor was rearranged so the door is not blocked.
3. Doors were dragging on the threshold and failed to latch, when closed, at the following locations:
a. Resident room 254, 156
all doors were repaired.
4. A one time full facility audit of all doors will be conducted to ensure that corridor doors properly close and resist the passage of smoke.
5. Education will be provided to maintenance staff on door closure requirements.
6 Accuracy audits on 5 random doors will be conducted monthly by the maintenance director or designee.
7. Date certain 11-5-24

NFPA 101 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to perform the required quarterly fire drills for staff, affecting the entire component.

Findings include:

1. Review of documentation on September 17, 2024, between 10:00 AM and 12:00 PM, revealed the facility did not perform required fire drills for the 1st and 2nd shifts, during the 3rd quarter, and no drill during the 3rd shift, on the 4th quarter.

Interview with the Administrator and Maintenance Man on September 17, 2024, at 2:00 PM, confirmed the fire drills were not conducted, as required.

Plan of Correction - To be completed: 11/05/2024

1. Fire drills were missed for 1st and 2nd shifts during the third quarter and no drill during the 3rd shift on the 4th quarter. We cannot go back and conduct these drills. A drill will be conducted once a month on a different shift to ensure that in the course of a quarter each shift is drilled.
2. this requirement will be placed in our maintenance tels system for monitoring and will be checked monthly by the maintenance director or designee.
3. Education will be provided to the maintenance staff on the importance of conducting fire drills on all shifts.
4. Results of the monthly drill will be reviewed by the QAPI committee and the fire drill matrix will be filled in and reviewed.
5. Date Certain is 11-5-24

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to ensure all rated/ labeled doors met the standard of NFPA 80 2010 Edition, on two of three floors within the component.

Findings include:

1. Review of documentation on September 17, 2024, between 10:00 AM and 12:00 PM, revealed the annual fire door inspection had not been performed.

Interview with the Administrator and the Maintenance Man on September 17, 2024, at 2:00 PM, confirmed the rated doors were not inspected, in the last twelve months.

Plan of Correction - To be completed: 11/05/2024

1.The annual fire door inspection had not been performed. The annual fire door inspection will be completed in October.
2. This requirement will be placed in our maintenance tels system for monitoring by the maintenance director or designee.
3. Education will be provided to the maintenance staff on the importance and requirement for a semi- annual fire door inspection.
4. An audit will be conducted semi-annually and results of the inspection will be reviewed by the QAPI committee.
5. Results will be filed in the life safety book.
6.. Date Certain is 11-5-24

NFPA 101 STANDARD Health Care Facilities Code - Other:

Health Care Facilities Code - Other
List in the REMARKS section any NFPA 99 requirements (excluding Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Health Care Facilities Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0900

Based on observation and interview, it was determined the facility failed to properly secure and separate oxygen cylinders, on one of three floors, which effected the entire component, per NFPA 99 2012 Edition 11.6.5.

Findings include:

1. Observation on September 17, 2024, at 12:15 PM, revealed the ground floor Oxygen Storage Room was only separated by a chain link fence, from a storage area with 3 propane tanks and a gas-fired snow blower.

Interview with the Maintenance Man on September 17, 2024, at 12:15 PM, confirmed the cylinders were not in a separate storage room.

Plan of Correction - To be completed: 11/05/2024

1. The ground floor oxygen storage room was only separated by a chain link fence, from the storage area with 3 propane tanks and a gas-fired snow blower. Oxygen and the gas fired equipment will be separated and moved to an appropriate storage location.
2. Education will be provided to the maintenance department on the need to separate the oxygen.
3. Weekly audits will occur for 1 month and quarterly thereafter for 1 year. Audits will be conducted by the maintenance director or designee.
4. Results of the audits will be reviewed by the QAPI committee.
5. Date certain is 11-5-24

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0915

Based on document review, observation and interview, it was determined the facility failed to provide a permanent emergency electrical system, affecting three of three floors within the component.

Findings include:

1. Review of documentation and observation on September 17, 2024, between 10:00 AM and 12:00 PM, revealed the facility relied on a temporary generator for at least the previous thirty-three months, and has not demonstrated progress in the acquisition of a permanent emergency electrical system, since November 2022.

Interview with the Administrator and the Maintenance Man on September 17, 2024, at 2:00 PM, confirmed the reliance upon a temporary generator, for more than 90 days.

Plan of Correction - To be completed: 11/05/2024

1. The temporary generator has been in place for at least 33 months. Plans for our permanent generator were submitted to the DOH and a virtual appointment took place on 9-27-24 to review the permanent plans. They said we should have a response in about 1 week. Our submission number is 47368 GWS.
2. Once our plans have been approved we will move forward with ordering the permanent generator.
3. This will be monitored by the administrator or designee.
4. The approved generator will be reviewed by the QAPI committee.
5. I am not sure what to put down as the date certain. I am being told that it will take about 1 year for the permanent generator to be ordered and installed.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide documentation of emergency generator fuel sample quality results, affecting the entire component.

Findings include:

1. Review of documentation on September 17, 2024, between 10:00 AM and 12:00 PM, revealed the facility failed to provide documentation, verifying the quality of the emergency fuel reserve, within the previous twelve months.

Interview with the Administrator and the Maintenance Man on September 17, 2024, at 2:00 PM, confirmed the lack of documentation.

Plan of Correction - To be completed: 11/05/2024

1. On 9-11-24 the load test was conducted on the emergency generator. In addition a fuel system test was conducted verifying the quality of the emergency fuel reserve. We have obtained a copy of the report.
2. This is an annual test that needs to be performed on the emergency generator. This requirement will be placed in our tels maintenance system for monitoring.
3. Education will be provided to the maintenance staff on the requirement of an annual load test and fuel system test on the emergency generator.
4. Results of the annual audit tool will be reviewed by the QAPI committee.
5. Date certain is 11-5-24

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain the proper usage and maintenance of electrical components, which affected the entire component.

Findings include:

1. Observation on September 17, 2024, at 12:30 PM, revealed the ground floor Mechanical Room, with all the electrical panels and main shut-off, was unlocked and accessible to any unauthorized persons.

Interview with the Maintenance Man on September 17, 2024, at 12:30 PM, confirmed the building electrical supply was accessible to any unauthorized persons.

Plan of Correction - To be completed: 11/05/2024

1. Mechanical room on ground floor was unlocked. Door has now been locked.
2. Education will be provided to the maintenance department on the requirement of the mechanical room being locked.
3. Audits will occur 3 times a week for 1 month and monthly thereafter for 1 year. Audits will be conducted by the maintenance director or designee.
4. Results of the audits will be reviewed by the QAPI committee.
5. Date certain is 11-5-24

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