Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on January 17, 2024, at Step By Step Inc Third, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 45661100
Component 01
Main building
Based on a Medicaid Recertification Survey completed on January 17, 2024, it was determined that Step by Step Inc. Third was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a three-story, Type V (111), protected wood frame building, with a basement, that is not sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - MAIN BUILDING 01 Component - 01
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 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:
Based on documentation review and interview, it was determined that the facility failed to maintain electrical receptacles in patient bed locations, in accordance with NFPA 99, 2012 edition, 6.3.4.1.3
Findings include:
1. Documentation review on January 17, 2024, at 8:55 a.m., revealed the facility lacked documentation for an annual tension and continuity test of non-hospital grade electrical receptacles in the resident sleeping rooms of the facility.
Interview with the Facility Administrator on January 17, 2024, at 11:00 a.m., confirmed the facility lacked documentation for an annual test of non-hospital grade electrical receptacles in resident sleeping areas, performed within the last 12 months.
Plan of Correction:The facility will maintain electrical receptacles in patient bed locations, in accordance with NFPA 99, 2012 edition 6.3.4.1.3.
The QIDP will schedule an annual tension and continuity test of non-hospital grade electrical receptacles in the resident sleeping rooms of the facility. The QIDP will receive a copy of the report and maintain the report at the facility. The QIDP will provide a quarterly report to the DRS for review designating the annual review of testing for the facility. (Target Date 4/15/2024)
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - MAIN BUILDING 01 Component - 01
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system in two instances affecting the entire facility.
Findings Include:
1. Review of documentation on January 17, 2024, revealed the following fire alarm system deficiencies:
a) 8:40 a.m., there were multiple uncorrected deficiencies on the last annual fire alarm inspection report;
b) 8:45 a.m., the facility failed to perform the semi-annual visual inspection.
Interview with the Facility Administator on January 17, 2024, at 11:00 a.m., confirmed the fire alarm system deficiencies.
Plan of Correction:The facility will maintain the fire alarm system.
The QIDP will schedule for the maintenance to be completed on the fire system to ensure the system is maintained and properly functioning (Target Date 4/15/2024). The QIDP will have a semi-annual visual inspection completed and documented at the facility (Target Date: 4/15/2024).
The QIDP will provide a quarterly report to the DRS for review relating to the fire system maintenance and any issues that have been identified. If an issue is identified, the QIDP will work to have the system repaired to ensure proper working order.
NFPA 101 STANDARD
Fire Drills
Name - MAIN BUILDING 01 Component - 01
Fire Drills
1. The facility must hold evacuation drills at least quarterly for each shift of personnel and under varied conditions to:
a. Ensure that all personnel on all shifts are trained to perform assigned tasks;
b. Ensure that all personnel on all shifts are familiar with the use of the facility's emergency and disaster plans and procedures.
2. The facility must:
a. Actually evacuate clients during at least one drill each year on each shift;
b. Make special provisions for the evacuation of clients with physical disabilities;
c. File a report and evaluation on each drill;
d. Investigate all problems with evacuation drills, including accidents and take corrective action; and
e. During fire drills, clients may be evacuated to a safe area in facilities certified under the Health Care Occupancies Chapter of the Life Safety Code.
3. Facilities must meet the requirements of paragraphs (i) (1) and (2) of this section for any live-in and relief staff that they utilize.
42 CFR 483.470(i)
Observations:
Based on documentation review and interview, it was determined the facility failed to perform eight of twelve required fire drills.
Findings include:
1. Review of documentation on January 17, 2024, at 9:10 a.m., revealed the facility lacked fire drill documentation for eight of twelve required fire drills.
Interview with the Facility Administrator on January 17, 2023, at 11:00 a.m., confirmed the facility failed to failed to perform eight of the twelve required fire drills.
Plan of Correction:The DRS will retrain the QIDP, DSSL, and all staff on standard evacuation drills (Target Date: 2/15/2024). The QIDP, or designee, will complete all fire drills in accordance with the fire drill schedule put together by the DRS. To ensure accuracy and completion, the QIDP or designee will complete the following steps when completing a fire drill:
1. Notify the system to be placed on test, in order to set the fire system off.
2. Complete the fire drill and each staff member will sign or initial completion of the drill.
3. The QIDP or designee will complete the fire drill form, sign and submit it for review to the DRS.
4. The QIDP will attach documentation from the fire system company showing when the system was turned off.
5. The DRS will review all fire drills for accuracy and sign off on documentation. A copy of the documentation will be kept in the regional office and the original will be kept on site.
The QIDP will provide this documentation for 6 months. (Target Date: 8/1/2024) The DRS will observe completion of the fire drills bi-monthly for 6 months to ensure accuracy. (Target Date: 8/1/2024)
NFPA 101 STANDARD
Maintenance, Inspection and Testing - Doors
Name - MAIN BUILDING 01 Component - 01
Maintenance, Inspection & Testing - Doors
Door assemblies where the door leaf is required to swing in the direction of egress travel are inspected and tested annually per 7.2.1.15.
Fire door assemblies are inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Smoke door assemblies are inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
Door assemblies are visually inspected on both sides and the requirements under 7.2.1.15.7 are verified.
Individuals performing the door inspection and testing have an understanding of the operating components of the doors.
Written records of inspection and testing are maintained and are available for review.
33.7.7, 7.2.1.15 (LSC)
5.2. 5.2.3 (NFPA 80)
5.2.1 (NFPA 105)
Observations:
Based on documentation review, observation and interview, it was determined that the facility failed to maintain fire rated door assemblies in three instances, affecting the entire facility.
Findings include:
1. Observation on January 17, 2024, revealed the following door deficiencies:
a) 9:30 a.m., the door leading to the basement failed to latch when tested;
b) 9:35 a.m., the door at the bottom of the stairs to the basement was propped open;
c) 10:05 a.m., the door to the attic failed to latch when tested.
Inteview with the Facility Administrator on January 17, 2024, at 11:00 a.m., confirmed the door deficiencies.
Plan of Correction:The facility will maintain fire-rated door assemblies.
The doors listed as a and c e will be repaired to ensure that they latch when tested. (Target Date: 4/15/2024). The QIDP will retrain all staff that all fire doors should remain closed. (Target Date: 2/15/2024).
The QIDP/PM will ensure that all doors latch when shut and will document those that fail on the weekly fire safety walkthrough. The QIDP will document that all doors are closed in the facility and will document it on the weekly fire safety walkthrough.
If the QIDP/PM identifies a door that does not latch, it will be reported to DRS to be repaired.
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