Nursing Investigation Results -

Pennsylvania Department of Health
BUCKTAIL MEDICAL CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BUCKTAIL MEDICAL CENTER
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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BUCKTAIL MEDICAL 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 October 9, 2019, it was determined that Bucktail Medical Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(d)(2) REQUIREMENT EP Testing Requirements: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.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

*[For LTC Facilities at 483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For RNHCIs at 403.748 and OPOs at 486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on documentation review and interview, it was determined the facility failed to conduct exercises, test, and evaluate an emergency plan.

Findings include:

1. Review of documentation on October 9, 2019, at 8:35 a.m., revealed the facility lacked records to support the required documentation needed to verify a second full scale exercise, or one table top exercise to test and evaluate an emergency plan.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 11/15/2019

The Maintenance Director was instructed to conduct an exercise that may include the following: (A) A second full-scale exercise that is community-based or individual, facility-based or (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

After the exercise, the maintenance director and other facility or community personnel involved in the exercise will analyze the facility's response to, and maintain documentation of, all drills, tabletop exercises, and emergency events, and recommend revisions to the facility's emergency plan, as needed.
Emergency preparedness exercises have been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit Emergency preparedness exercises annually.

Results of this audit will be reported at the Monthly QA meeting. Emergency preparedness exercises will remain a QI of the QA Program until 100% compliance has been achieved and maintained for eighteen (18) months.

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


Facility ID# 549602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on October 9, 2019, it was determined that Bucktail Medical 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 483.70(a).

This is a one story, Type II (111), protected, noncombustible structure, 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 01 - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the following item(s) did not meet 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 within the facility.

Findings include:

1. Review of documentation on October 9, 2019, at 8:30 a.m., revealed the facility installed a new fire alarm system without approved plans from the Pennsylvania Department of Health.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the new fire alarm system installation.





 Plan of Correction - To be completed: 10/21/2019

Pennsylvania Department of Health, Plan Review, was contacted on October 28, 2019 and advised that the fire alarm system has been upgraded from an analog system to a fully addressable system.

Plan review requested that plans of the work be submitted for review.

Plans will be uploaded for review.

Administrator will insure any future changes to the facility will be submitted for plan review before work commences.
NFPA 101 STANDARD Building Construction Type and Height: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.
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 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain fire rated construction, affecting one of three smoke compartments in the facility.

Findings include:

1. Observation on October 9, 2019, at 10:00 a.m., revealed a corridor light located near resident room #200 lacked bonnet protection.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the lack of required one-hour protection.





 Plan of Correction - To be completed: 10/30/2019

Bonnet protection was restored to the corridor light located near resident room #200.

All other corridor ceiling lights were inspected to confirm bonnet protection was in place.

Bonnet protection around corridor lights has been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.
The Maintenance Director will audit bonnet protection for corridor lighting each month.

Results of this audit will be reported at the Monthly QA meeting. Bonnet protection around corridor lights will remain a QI of the QA Program until 100% compliance has been achieved and maintained for three (3) consecutive months.

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 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress, affecting one of three smoke compartments within the facility.

Findings include:

1. Observation on October 9, 2019, at 10:15 a.m., revealed the Long Hall exit door needed excessive force to be opened.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the exit door needed excessive force to be opened.




 Plan of Correction - To be completed: 10/22/2019

The Long Hall exit door was serviced by maintenance staff on 10/22/2019 so that it opened freely and without excessive force.

All other exit doors were inspected and serviced as necessary so that they open freely and without excessive force.

Exit doors opening freely and without excessive force has been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit exit doors opening freely and without excessive force monthly.

Results of this audit will be reported at the Monthly QA meeting. Exit doors opening freely and without excessive force will remain a QI of the QA Program until 100% compliance has been achieved and maintained for three (3) consecutive months.

NFPA 101 STANDARD Cooking Facilities: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.
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 01 - Component: 01 - Tag: 0324

Based on documentation and interview, it was determined the facility failed to maintain the dietary suppression system during the past year.

Findings include:

1. Review of documentation on October 9, 2019, at 8:40 a.m., revealed the facility lacked documentation to support one of two required semi-annual kitchen hood suppression system inspections during the past year.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the facility lacked documentation.





 Plan of Correction - To be completed: 10/30/2019

A required semi-annual kitchen hood suppression system inspection was completed on October 21, 2019.

The maintenance director will be responsible to schedule required semi-annual kitchen hood suppression system inspections two times each year. The time between cleanings can not exceed six (6) months.

Required semi-annual kitchen hood suppression system inspections have been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit required semi-annual kitchen hood suppression system inspections monthly.

Results of this audit will be reported at the Monthly QA meeting. Required semi-annual kitchen hood suppression system inspections will remain a QI of the QA Program until 100% compliance has been achieved and maintained for three (3) consecutive inspections.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 - Component: 01 - Tag: 0353

Based on documentation review and interview, it was determined the facility failed to maintain sprinkler systems in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on October 9, 2019, at 8:25 a.m., revealed the most recent sprinkler inspection report stated the pit devices were removed from the system, including the fire pump being out of order.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the documentation report.




 Plan of Correction - To be completed: 12/08/2019

The equipment in the sprinkler vault, including the fire pump, was damaged when the vault flooded. The incident was reported and the facility is working with contractors, the local communities, and local water authorities to identify viable solutions.

While the condition is evaluated, the facility does have sprinkler coverage; only the sprinkler vault, which provides additional water pressure when necessary, was damaged.

Flow tests have been completed both at the two inch (2") drain valve and at a fire hydrant to verify water flow and pressure while the fire pump is not operational.

A fire watch was implemented and continues.

The Facility has put the following additional safeguards in place:
- A fire hose is connected to the fire hose connection for the facility, allowing immediate hook up to the facility sprinkler system.

- Both local fire companies have been alerted to the condition and,
- Both local fire companies are keeping their tanker trucks filled while not in use: Total volume of water available is nearly 5,000 gallons; double the capacity of the tank in the fire pit.

Necessary repairs to the sprinkler pit will be completed within 60 days.
NFPA 101 STANDARD Fire Drills: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.
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 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to conduct one of twelve required fire drills during the past year.

Findings include:

1. Review of documentation on October 9, 2019, at 8:32 a.m., revealed the facility did not have records available to support conducting a fire drill on the 3rd shift during the 4th calendar quarter of the past year.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the facility lacked documentation.





 Plan of Correction - To be completed: 11/15/2019

A third shift fire drill was conducted on October 23, 2019 at 2:00 am.
The maintenance director will be responsible to schedule fire drills as follows:

1 First shift fire drill each calendar quarter. The time for each quarterly first shift fire drill will vary throughout the shift.

1 Second shift fire drill per calendar quarter. The time for each quarterly second shift fire drill will vary throughout the shift.

1 Third shift fire drill per calendar quarter. The time for each quarterly third shift fire drill will vary throughout the shift.

To ensure compliance with this schedule, the Maintenance Director will schedule the date and time of required fire drills for the next eighteen (18) months.

Fire drills have been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit required semi-annual kitchen hood suppression system inspections monthly.
Results of this audit will be reported at the Monthly QA meeting. Fire drills will remain a QI of the QA Program until 100% compliance has been achieved and maintained for eighteen (18) months.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
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 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to provide the annual inspection of all fire rated doors, affecting three of three smoke compartments within the facility.

Findings include:

1. Review of documentation on October 9, 2019, at 8:20 a.m., revealed the facility failed to perform required annual fire door inspections.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the lack of fire door inspections.





 Plan of Correction - To be completed: 10/22/2019

A required annual fire door inspection was completed on 10/22/2019.

The inspection included examination of the following components:
Door operation, door frame, the door, hinges and pivots, flush bolts, locksets and latches, fire exit hardware, door closer, labeling, and seals. The inspection was documented using a Detailed Checklist for Fire Door Assembly Inspection.

The maintenance director will be responsible to complete the required annual fire door inspection each October, using the process and checklist described above.

Required annual fire door inspection has been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit required annual fire door inspection annually.

Results of this audit will be reported at the Monthly QA meeting. Required annual fire door inspection will remain a QI of the QA Program until 100% compliance has been achieved and maintained for three (3) consecutive years.

NFPA 101 STANDARD Electrical Systems - Other: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 - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain emergency generators in one instance, affecting the entire facility.

Findings include:

1. Observation on October 9, 2019, at 8:46 a.m., revealed the facility lacked a remotely located emergency stop.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the lack of an emergency stop.




 Plan of Correction - To be completed: 11/30/2019

A remote emergency stop will be installed for the emergency generator during the annual maintenance and load test, which is scheduled to be completed by the end of November 2019.

The Maintenance Director will ensure the switch is installed as required.

The Maintence Director will monitor proper operation of the switch monthly.

Remote emergency stop operation has been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit remote emergency stop operation monthly.

Results of this audit will be reported at the Monthly QA meeting. Remote emergency stop operation will remain a QI of the QA Program until 100% compliance has been achieved and maintained for three (3) consecutive months.
NFPA 101 STANDARD Electrical Systems - Maintenance and Testing: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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, the facility failed to maintain electrical receptacles affecting the entire facility.

Findings include:

1. Review of documentation on October 9, 2019, at 9:49 a.m., revealed the facility lacked documentation for a required annual electrical receptacle inspection (non-hospital grade receptacles only).

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 11/15/2019

A required annual electrical receptacle inspection of non-hospital grade receptacles on or before 11/15/2019.

The inspection will include a pass/fail examination of the following components:
Physical condition, ground continuity, polarity check, and ground retention.

The maintenance director will be responsible to complete the required annual electrical receptacle inspection of non-hospital grade receptacles annually, not to exceed 365 days between tests, using the process and checklist described above.

Required electrical receptacle inspection of non-hospital grade receptacles has been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit required electrical receptacle inspection of non-hospital grade receptacles annually.

Results of this audit will be reported at the Monthly QA meeting. Required semi-annual kitchen hood suppression system inspections will remain a QI of the QA Program until 100% compliance has been achieved and maintained for three (3) consecutive years.

NFPA 101 STANDARD Electrical Equipment - Other: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 Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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.
Chapter 10 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

Based on documentation review, observation, and interview, it was determined the facility failed to maintain generators in two instances, affecting three of three smoke compartments within the component.

Findings include:

1. Review of documentation on October 9, 2019, at 8:43 a.m., revealed the facility lacked the required weekly voltage testing of the emergency generators sealed battery.

2. Observation on October 9, 2019, at 11:10 a.m., revealed the facility lacked a minimum of 30 inches of working space around the unit due to storage.

Exit interview with facility administrator and facility representative #1 on October 9, 2019, at 11:45 a.m., confirmed the lack of documentation and work space.




 Plan of Correction - To be completed: 11/08/2019

1. A required weekly voltage test of the emergency generators sealed battery was conducted on 10/22/2019.

The maintenance director will be responsible to schedule required weekly voltage testing of the emergency generators sealed battery each week in conjunction with the weekly generator run test.

Required weekly voltage testing of the emergency generators sealed battery has been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit required weekly voltage testing of the emergency generators sealed battery monthly.

Results of this audit will be reported at the Monthly QA meeting.

Required weekly voltage testing of the emergency generators sealed battery will remain a QI of the QA Program until 100% compliance has been achieved and maintained for three (3) consecutive months.

2. Items stored within thirty (30) inches of the generator were removed and relocated..

Monitoring for thirty (30) inches of clearnace around the generator has been added as a Quality Indicator (QI) for the Quality Assurance (QA) Program with a goal of 100% compliance.

The Maintenance Director will audit thirty (30) inches of clearnace around the generator monthly.

Results of this audit will be reported at the Monthly QA meeting.

Thirty (30) inches of clearnace around the generator will remain a QI of the QA Program until 100% compliance has been achieved and maintained for three (3) consecutive months.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID# 549602
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on October 9, 2019, at Bucktail Medical Center, it was determined there were no deficiencies identified under the 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 483.70(a).

This is a one story, Type II (000), unprotected, noncombustible structure, which is fully sprinklered structure.




 Plan of Correction:



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