Based on the findings of an onsite unannounced followup survey completed on September 28, 2017, Butler Rehabilitation Centers had not corrected the following deficiency cited under 42 CFR, Chapter IV, Subpart B, Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities. The deficiency was cited as a result of a Medicare recertification survey completed on June 14, 2017.
Plan of Correction:
Name - Component - 00
The facility must establish a written preventive maintenance program to ensure that all equipment is properly maintained and equipment needing periodic calibration is calibrated consistent with the manufacturer's recommendations.
Based on review of facility evacuation map, compliance checklist, and policy and procedure manual, observation, and staff (EMP) interview, the facility failed to ensure the maintenance of three (3) of three (3) fire extinguishers located in the facility (FE1, FE2, & FE3).
Review of facility's evacuation map hanging on wall revealed facility has three (3) fire extinguishers listed: FE1 located in patient waiting room, FE2 located in kitchen, and FE3 located in hallway outside entrance to facility.
Observation in the patient waiting area on September 28, 2017, at 10:00 a.m. revealed a fire extinguisher (FE1) mounted on the wall and inspected on October 2016. Review of the back side of the tag hanging from extinguisher revealed it was never inspected monthly.
Observation of facility kitchen on September 28, 2017, at 10:18 a.m. revealed a fire extinguisher (FE2) that had been installed on June 2017. Review of the back side of tag hanging from extinguisher revealed no documented monthly inspection for July or August.
Obseravtion of hallway outside facility entrance on September 28, 2017, at 10:25 a.m. revealed a fire extinguisher (FE3) listed on facility's evacuation map. The extinguisher was serviced and installed on January 2017. Review of back side of tag hanging from extinguisher revealed it was never inspected monthly.
Interview with EMP1 (alternate administrator) on September 28, 2017, at 10:30 a.m. confirmed no documentation to show fire extinguishers were inspected monthly per facility policy.
A review of "Annual Compliance Checklist" was conducted on September 28, 2017, at 10:33 a.m. This checklist is used to maintain the fire extinguishers' annual inspection. According to this list the Butler location has two (2) fire extinguishers. One located in the kitchen (FE2) and one located in the in the waiting room (FE1); no mention of the fire extinguisher in the hallway (FE3) as listed on facility evacuation map. Interview with EMP1 at time of review confirmed FE3 not listed on facility's annual compliance checklist used to maintain fire extinguishers.
Review of facility policy and procedure manual, "Butler Rehabilitation Centers Policy and Operations Manual" on September 28, 2017, at 10:40 a.m. showed, "Fire Alarm and Extinguishers - Exit Lights: ... Fire extinguishers are inspected monthly for condition by a staff member, and annually by an outside certified professional."
Plan of Correction:
(FE3) located in the hallway is no longer maintained and inspected by Butler Rehabilitation Centers. A new building occupant has since obtained control of that particular extinguisher. As a result, that extinguisher was removed from facilities evacuation maps on 10/6/2017.
To correct the aforementioned deficiency of no monthly fire extinguisher checks, BRC has appointed staff members of each facility to perform monthly inspections of extinguishers, including initialing and dating the back of the extinguisher tag for each facility extinguisher. This was completed on 10/6/2017.
In addition, this topic of checking extinguishers monthly will be placed on the quarterly compliance meetings with all staff members. This meeting is scheduled for 10/11/2017. All staff will be educated about monthly extinguisher checks and will be educated on how to check each extinguisher monthly. This was completed on 10/11/2017.
To ensure this deficiency does not occur in the future, the BRC management has developed a monthly checklist to be performed by administrator and assistant administrator and this will include fire extinguisher checks and initialing bag tags with date to be performed every month until the annual fire extinguisher check. This was completed on 10/6/2017.