Nursing Investigation Results -

Pennsylvania Department of Health
ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  37 surveys for this facility. Please select a date to view the survey results.

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ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
483.73(a) REQUIREMENT Develop EP Plan, Review and Update Annually: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.
The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.

The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at 482.15 and CAHs at 485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at 483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually.

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined the facility failed develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually affecting one of one plan.

Findings include:

1. Document review on January 27, 2020, at 10:35 a.m., revealed the facility failed to conduct the required annual review of its Emergency Preparedness Plan.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the facility did not conduct the required annual review of its Emergency Preparedness Plan.





 Plan of Correction - To be completed: 03/10/2020

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared in accordance with federal and state law requirements.


E0004
It is the practice of the facility to have an emergency preparedness plan that is reviewed and updated annually.
-The facility provides an emergency preparedness plan that will be updated and reviewed annually.
-The Plant Director/designee will monitor the emergency preparedness plan to ensure that it is updated and reviewed annually.
-The update and review findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.


483.73(a)(4) REQUIREMENT Local, State, Tribal Collaboration Process: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.
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years (annually for LTC facilities). The plan must do the following:]

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

* [For ESRD facilities only at 494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Name: - Component: -- - Tag: 0009

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness Plan to include the facilities efforts to contact, cooperate and collaborate with efforts of local and regional emergency planning.

Findings include:

1. Document review on January 27, 2020, at 11:00 a.m., revealed the facility failed to develop an Emergency Preparedness Plan to include the facilities efforts to contact, cooperate and collaborate with efforts of local and regional emergency planning.

Interview at the exit conference with the Regional Maintenance Director, and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the facility failed to develop an Emergency Preparedness Plan to include the facilities efforts to contact, cooperate and collaborate with efforts of local and regional emergency planning.





 Plan of Correction - To be completed: 03/10/2020

E0009
It is the practice of the facility to have an emergency preparedness plan that includes efforts to contact, cooperate and collaborate with efforts of local and regional emergency planning.
-The facility provides an emergency preparedness plan that identifies efforts to contact officials to engage in collaborative planning for an integrated emergency response.
-The Plant Director/designee will inspect the emergency preparedness plan to ensure that efforts were identified to contact officials to engage in collaborative planning for an integrated emergency response.
-The inspection findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.

483.73(c)(7) REQUIREMENT Information on Occupancy/Needs: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.
[(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at 418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Name: - Component: -- - Tag: 0034

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness communication plan that includes a means for providing information about the facility's occupancy, needs, and ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, in one of one plan.

Findings include

1. Document review on January 27, 2020, at 11:20 a.m., revealed the facility failed to develop an emergency plan that includes a means for providing information about the facility's occupancy, needs, and ability to provide assistance, to the authority having jurisdiction, an Incident Command Center, or designee.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the facility failed to develop an emergency plan to include a means for providing information about the facility's occupancy, needs, and ability to provide assistance.





 Plan of Correction - To be completed: 03/10/2020

E0034
It is the practice of the facility to have an emergency preparedness plan that includes a means for providing information about the facility's occupancy, needs, and ability to provide assistance, to the authority having jurisdiction, an Incident Command Center, or designee.
-The emergency preparedness plan will include a means for providing information about the facility's occupancy, needs, and ability to provide assistance, to the authority having jurisdiction, an Incident Command Center, or designee.
-The Plant Director/designee will inspect the emergency preparedness plan to ensure the facility's occupancy, needs, and ability to provide assistance, to the authority having jurisdiction, an Incident Command Center, or designee are included in plan.
-The inspection findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.

483.73(d)(1) REQUIREMENT EP Training Program: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.
*[For RNCHIs at 403.748, ASCs at 416.54, Hospitals at 482.15, ICF/IIDs at 483.475, HHAs at 484.102, "Organizations" under 485.727, OPOs at 486.360, RHC/FQHCs at 491.12:] (1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.

*[For Hospices at 418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures.

*[For PRTFs at 441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.

*[For LTC Facilities at 483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at 485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.

*[For CAHs at 485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.

*[For CMHCs at 485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Name: - Component: -- - Tag: 0037

Based on document review and interview, it was determined the facility failed to develop and maintain an emergency preparedness training program for staff and individuals providing services to the facility, affecting one of one plan.

Findings include:

1. Document review on January 27, 2020, at 11:30 a.m., revealed the facility failed to provide documentation showing their emergency preparedness training program for staff, individuals providing services to the facility including volunteers.

Interview at the exit conference with the Regional Maintenance Director, and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed documentation of their emergency preparedness training program was unavailable.





 Plan of Correction - To be completed: 03/10/2020

E0037
It is the practice of the facility to have an emergency preparedness training program for staff and individuals providing services to the facility.
-The facility will provide documentation showing the emergency preparedness training program for staff and individuals providing services to the facility including volunteers.
-The Plant Director/designee will audit that the emergency preparedness training program to ensure completion of training.
-The audit findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.

Initial comments:Name: MAIN BUILDING 01 (ORIGINAL & SUBACUTE CARE BLDG) - Component: 01 - Tag: 0000


Facility ID# 232602
Component 01
Original and Subacute Care Building

Based on a Medicare/Medicaid Recertification Survey conducted on January 27, 2020, it was determined that St. Monica Center For Rehabilitation & Healthcare - Original and Subacute Care Building, 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 three-story, Type II (222), fire-resistive structure, with a lower level, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 (ORIGINAL & SUBACUTE CARE BLDG) - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stair tower doors in one of four stair towers.

Findings include:

1. Observation on January 27, 2020, at 12:20 p.m., revealed Basement Stair Tower 1 door had a gap between the door leaves, which would not resist the passage of smoke.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the gap in the rated door assembly.





 Plan of Correction - To be completed: 03/10/2020


K0225
It is the practice of the facility to maintain stair tower doors.
-The stair tower door gap was sealed to prevent the passage of smoke.
--The Plant Director/designee will audit that the stair tower doors are sealed to prevent the passage of smoke.
--The audit findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 01 (ORIGINAL & SUBACUTE CARE BLDG) - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components on two of three floors.

Findings include:

1. Observation on January 28, 2020, between 12:10 p.m. and 1:25 p.m., revealed missing ceiling tiles, which could delay activation of the sprinklers in the following locations:

a. 12:10 p.m., Basement kitchen janitorial supply.
b. 1:25 p.m., 2nd floor Spa phone room.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the missing ceiling tiles.

2. Observation on January 27, 2020, at 1:15 p.m., revealed, in 2nd floor Recreational supply, a sprinkler was missing its escutcheon.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the missing escutcheon.





 Plan of Correction - To be completed: 03/10/2020

K0353
It is the practice of the facility to maintain automatic sprinkler system components.
-The janitorial supply and 2nd floor spa phone room will have the ceiling tiles installed. The escutcheon was replaced in the 2nd floor Recreation Supply.
--The Plant Director/designee will audit that the ceiling tiles are in place and that the sprinklers have escutcheon plates.
--The audit findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.

NFPA 101 STANDARD Fire Drills: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.
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 01 (ORIGINAL & SUBACUTE CARE BLDG) - Component: 01 - Tag: 0712

Based on observation and interview, it was determined the facility failed to ensure fire drills were conducted at unexpected times, affecting eight of twelve quarters.

Findings include:

1. Document review on January 27, 2020, at 9:00 a.m., revealed the following fire drills were held in the same hours throughout the year:

a. 2nd shift, all drills conducted during 3:00 p.m. hour.
b. 3rd shift, all drills conducted during 5:00 a.m. hour.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the above listed fire drills were not held at unexpected times.





 Plan of Correction - To be completed: 03/10/2020

K0712
It is the practice of the facility to ensure fire drills are conducted at unexpected times.
-Fire drills will be conducted at varying unexpected times on each shift.
--The Plant Director/designee will audit that the fire drills are scheduled and conducted at varying unexpected times during each shift.
--The audit findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 01 (ORIGINAL & SUBACUTE CARE BLDG) - Component: 01 - Tag: 0915

Based on document review and interview, it was determined the facility failed to maintain the emergency generator, affecting emergency power to the entire facility.

Findings include:

1. Observation on January 27, 2020, between 12:00 p.m. and 2:15 p.m., revealed there was no remote manual stop station provided for the following generators:

a. 12:00 pm, lower level generator.
b. 2:15 pm, exterior generator.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the missing remote manual stop stations.





 Plan of Correction - To be completed: 03/10/2020

K0915
It is the practice of the facility to maintain the emergency generators.
-The lower and exterior generators will have remote manual stop stations provided.
--The Plant Director/designee will audit that the generators have remote manual stop stations provided.
--The audit findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.

Initial comments:Name: CHAPEL, PHYSICAL THERAPY, BUSINESS OFFICES - Component: 03 - Tag: 0000


Facility ID# 232602
Component 03
Chapel, Physical Therapy and Business Offices

Based on a Medicare/Medicaid Recertification Survey conducted on January 27, 2020, it was determined that St. Monica Center For Rehabilitation & Healthcare - Chapel, Physical Therapy and Business Offices, 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 one-story, Type IV (2HH), heavy timber structure, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Receptacles: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.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: CHAPEL, PHYSICAL THERAPY, BUSINESS OFFICES - Component: 03 - Tag: 0912

Based on observation and interview, the facility failed to maintain electric systems in wet locations, affecting one of two smoke compartments within this component.

Findings include:

1. Observation on January 27, 2020, at 12:40 p.m., revealed, in 1st floor Physical Therapy Department, a hydrocollator was not plugged into a Ground Fault Circuit Interrupter (GFCI) receptacle.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the hydrocollator was not plugged into a GFCI receptacle.





 Plan of Correction - To be completed: 03/10/2020

K0912
It is the practice of the facility to maintain electric systems in wet locations.
-The hydrocollator plug was changed to a ground fault circuit interrupter (GFCI) receptacle.
--The Plant Director/designee will audit that the receptacles in wet locations are (GFCI) receptacles.
--The audit findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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: CHAPEL, PHYSICAL THERAPY, BUSINESS OFFICES - Component: 03 - Tag: 0915

Based on document review and interview, it was determined the facility failed to maintain the emergency generator, affecting emergency power to the entire facility.

Findings include:

1. Observation on January 27, 2020, between 12:00 p.m. and 2:15 p.m., revealed there was no remote manual stop station provided for following the generators:

a. 12:00 pm, lower level generator.
b. 2:15 pm, exterior generator.

Interview at the exit conference with the Regional Maintenance Director and the Maintenance Director on January 27, 2020, at 2:35 p.m., confirmed the missing remote manual stop stations.





 Plan of Correction - To be completed: 03/10/2020

K0915
It is the practice of the facility to maintain the emergency generators.
-The lower and exterior generators will have remote manual stop stations provided.
--The Plant Director/designee will audit that the generators have a remote manual stop stations provided.
--The audit findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 3/10/2020.



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