D E P A R T M E N T 0 F HEALTH & WELFARE

Transcription

1 I D A H 0 D E P A R T M E N T 0 F HEALTH & WELFARE C.L. HBUTCH" OTTER- Governor RICHARD M. ARMSTRONG - Director DEBRA RANSOM, R.N.,R.H.I.T., Chief BUREAU OF FACILITY STANDARDS 3232 Elder Street P.O. Box83720 Boise, PHONE FAX CERTIFIED MAIL: August 1, 2013 Michael G. Andrus, Administrator Franklin County Transitional Care 44 North 1st East Preston, ID Provider#: Dear Mr. Andrus: On July 24, 2013, a Facility Fire Safety and Construction survey was conducted at Franklin County Transitional Care by the Department of Health & Welfare, Bureau of Facility Standards to determine if your facility was in compliance with State Licensure and Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs. This survey found that your facility was not in substantial compliance with Medicare and Medicaid program participation requirements. This survey found the most serious deficiency to be a widespread deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy, as documented on the enclosed CMS-2567, whereby significant corrections are required. Enclosed is a Statement of Deficiencies and Plan of Correction, Form CMS-2567, listing Medicare and/or Medicaid deficiencies, and a similar State Form listing licensure health deficiencies. In the spaces provided on the right side of each sheet, answer each deficiency and state the date when each will be completed. Please provide ONLY Ol\lE completion date for each federal and state Tag in column X5 (Completion Date), to signify when you allege that each tag will be back in compliance. NOTE: The alleged compliance date must be after the "Date Survey Completed" (located in field X3) and on or before the "Opportunity to Correct" (listed on page 2). After each deficiency has been answered and dated, the administrator should sign both Statement of Deficiencies and Plan of Correction, Form CMS-2567 and State Form, in the spaces

2 Michael G. Andrus, Administrator August 1, 2013 Page 2 of 4 provided and return the originals to this office. Your Plan of Correction (PoC) for the deficiencies must be submitted by August 14, Failure to submit an acceptable PoC by August 14, 2013, may result in the imposition of civil monetary penalties by September 3, Your PoC must contain the following: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action( s) will be taken; What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and, Include dates when corrective action will be completed. All references to federal regulatory requirements contained in this letter are found in Title 42, Code of Federal Regulations. Remedies will be recommended for imposition by the Centers for Medicare and Medicaid Services (CMS), if your facility has failed to achieve substantial compliance by August 28,2013, (Opportunity to Correct). Informal dispute resolution of the cited deficiencies will not delay the imposition of the enforcement actions recommended (or revised, as appropriate) on August 28, A change in the seriousness of the deficiencies on August 28,2013, may result in a change in the remedy. The remedy, which will be recommended if substantial compliance has not been achieved by August 28, 2013, includes the following: Denial of payment for new admissions effective October 24, CFR (a) If you do not achieve substantial compliance within three (3) months after the last day of the survey identifying noncompliance, the CMS Regional Office and/or State Medicaid Agency must

3 Michael G. Andrus, Administrator August 1,2013 Page 3 of 4 deny payments for new admissions. We must recommend to the CMS Regional Office and/or State Medicaid Agency that your provider agreement be terminated on January 24, 2014, if substantial compliance is not achieved by that time. Please note that this notice does not constitute formal notice of imposition of alternative remedies or termination of your provider agreement. Should the Centers for Medicare & Medicaid Services determine that termination or any other remedy is warranted, it will provide you with a separate formal notification of that determination. If you believe these deficiencies have been corrected, you may contact Mark P. Grimes, Supervisor, Facility Fire Safety and Construction, Bmeau of Facility Standards, 3232 Elder Street, PO Box 83720, Boise, ID , Phone#: (208) , Fax#: (208) , with your written credible allegation of compliance. If you choose and so indicate, the PoC may constitute your allegation of compliance. We may accept the written allegation of compliance and presume compliance until substantiated by a revisit or other means. In such a case, neither the CMS Regional Office nor the State Medicaid Agency will impose the previously recommended remedy, if appropriate. If, upon the subsequent revisit, your facility has not achieved substantial compliance, we will recommend that the remedies previously mentioned in this letter be imposed by the CMS Regional Office or the State Medicaid Agency beginning on July 24, 2013, and continue until substantial compliance is achieved. Additionally, the CMS Regional Office or State Medicaid Agency may impose a revised remedy(ies ), based on changes in the seriousness of the non-compliance at the time of the revisit, if appropriate. In accordance with 42 CFR , you have one opportunity to question cited deficiencies through an informal dispute resolution process. To be given such an opportunity, you are required to send your written request and all required infonnation as directed in Informational Letter # Informational Letter # can also be found on the Internet at: Jhealthandwelfare. idaho. gov /Pro vi ders/providersf aciliti es/statef ederalpro grams,in ursingf a cilities/tabid/ 4 34/Default.aspx Go to the middle of the page to Information Letters section and click on State and select the following: BFS Letters (06/30/11)

4 Michael G. Andrus, Administrator August 1, 2013 Page 4 of Long Term Care Informal Dispute Resolution Process IDR Request Form This request must be received by August 14,2013. If your request for informal dispute resolution is received after August 14, 2013, the request will not be granted. An incomplete informal dispute resolution process will not delay the effective date of any enforcement action. Thank you for the courtesies extended to us duting the survey. If you have any questions, please contact us at (208) Mark P. Grimes, Supervisor Facility Fire Safety and Construction M:PG/dmj Enclosures

5 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIOER/SUPPUER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 -ENTIRE NF BUILDING Printed: 07/30/2013 FORM APPROVED OMB NO (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER FRANKLIN COUNTY TRANSITIONAL CARE B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 44 NORTH 1ST EAST PRESTON, ID /24/2013 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE K 000 INITIAL COMMENTS K 000 The facility is a single story type II (111) building with a complete sprinkler system that was installed in July The plans for the building were approved in 1970 and construction completed in There have been subsequent remodels. Currently the facility is licensed for 35 NF beds. The following deficiencies were cited during the annual fire/life safety survey conducted on July 24, The facility was surveyed under the LIFE SAFETY CODE, 2000 Edition, Existing Health Care Occupancy, in accordance with 42 CFR The Survey was conducted by: Tom Mroz CFI-11 Health Facility Surveyor Facility Fire Safety and Construction K 025 NFPA 101 LIFE SAFETY CODE STANDARD SS=F Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully dueled heating, ventilating, and air conditioning systems , , , K025 LABORATORY DIRECTOR'S OR PROVIDE )\.1.V Any deficiency statement el]dipif~i an asterisk(*) es a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide s6fficient protection tot pat' nts. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a pi of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are ade available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete ZLXU21 If continuation sheet Page 1 of 4

6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING 01 - ENTIRE NF BUILDING Printed: 07/30/2013 FORM APPROVED OMB NO (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER FRANKLIN COUNTY TRANSITIONAL CARE B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 44 NORTH 1ST EAST PRESTON, ID /24/2013 (X4) ID! SUMMARY STATEMENT OF DEFICIENCIES i(each DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY I OR LSC IDENTIFYING INFORMATION) I K 025 Continued From page 1 failed to maintain the smoke resistive properties of a smoke barrier wall. This potentially exposed residents to a smoke or fire environment. The deficient practice affected two of five smoke compartments, staff, and 12 residents. The facility is licensed for 35 beds and had a census of 32 on the day of survey. ID K 025 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Findings include: 1.) Observation on 07/24/13 at 10:35 a.m., revealed a three inch wall penetration in the annular space around data cables in the ceiling above the cross corridor doors by C-wing room 36. Interview with the Maintenance Supervisor revealed data wires were recently run through the barriers. 2.) Observation on 07/24/13 at 11:15 a.m., revealed that the fire/smoke barrier walls above the ceiling tile assembly located at the cross corridor doors separating the pharmacy and housekeeping room had multiple conduit, wire and pipe penetrations that were not sealed. Interview with the Maintenance Supervisor on 07/24/13 at 11:15 a.m., revealed that the facility was not aware of the unsealed penetrations in the smoke barrier walls. The findings were acknowledged by the Administrator and verified by the facility Maintenance Supervisor at the exit interview on 07/24/13. Actual NFPAStandard: NFPA 101, Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour. Actual NFPA Standard: NFPA 101, (1) a. FORM CMS-2567(02-99} Previous Versions Obsolete ZLXU21 If contmuat1on sheet Page 2 of 4

7 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING 01 - ENTIRE NF BUILDING Printed: 07/30/2013 FORM APPROVED OMB NO (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER FRANKLIN COUNTY TRANSITIONAL CARE B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 44 NORTH 1ST EAST PRESTON, ID /24/2013 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES I (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATOR~ OR LSC IDENTIFYING INFORMATION), ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE K 025 K 147 This Standard is.not met as evidenced by: Based on observation and interview the facility did not ensure that electrical wiring and equipment usage was in accordance with NFPA 70, National Electric Code. Electric wiring run through walls can overheat and or short out and start a fire. The deficient practice affected one of five smoke compartments, staff, and no residents. The facility is licensed for 35 beds and had a census of 32 on the day of survey. Findings include: During the tour of the facility on 07/24/13 at 10:35 a.m., observation in the kitchen, attached to the northeast wall, was a relocatable power tap with an electric power cord plugged into it that was run through a hole in the wall powering an automatic door opener for the double glass doors in the corridor adjacent to the kitchen. Interview with the Maintenance Supervisor revealed the facility was unaware power cords could not be run through holes in the wall. This was observed and noted by the Facility Administrator, Maintenance I FORM CMS-2567(02-99) Previous Versions Obsolete ZLXU21 If continuation sheet Page 3 of 4

8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 -ENTIRE NF BUILDING Printed: 07/30/2013 FORM APPROVED OMB NO (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER FRANKLIN COUNTY TRANSITIONAL CARE B. WING STREET ADDRESS, CITY, STATE, ZIP CODE, 44 NORTH 1ST EAST PRESTON, ID /24/2013 (X4) ID II SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) : ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) : (X5). COMPLETION ' DATE K 147 Continued From page 3 Supervisor, and Surveyor. K 147 The findings were acknowledged by the Administrator and verified by the facility Maintenance Supervisor at the exit interview on 07/24/13. Actual Code Reference NFPA 70 National Electrical Code 1999 Edition Uses Not Permitted Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following: 1. As a substitute for the fixed wiring of a structure 2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors 3. Where run through doorways, windows, or similar openings 4. Where attached to building surfaces Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors 6. Where installed in raceways, except as otherwise permitted in this Code I FORM CMS-2567(02-99) Previous Versions Obsolete I ZLXU21 If contmuatton sheet Page 4 of 4

9 To whom it may concern: This is a (Poe) for deficiencies that were found on July 24, ForK 025 tag, the corrective action will be to fix and patch the penetrations in the annular space where data cables crossed a smoke barrier to make ~!zjpj~it is at least one half hour fire resistance rating in accordance with 8.3. See attached photo.l.l. Also the barrier wall above the ceiling tile assembly located at the cross corridor doors separating the _p~macy and housekeeping room which had the multiple conduits, wire and pipe penetrations sealed and fixed in accordance with 8.3. To make sure it is at least one half hour fire resistance. See attached photo.l.2. By fixing these two areas of penetration we have identified that there are no other residents having the potential to be affected. There will be a monthly check to make sure there have been no penetrations unsealed. This will be done once a month by the maintenance manager and documented and dated. The corrective action will be monitored by the maintenance manager every first week on the month in the fire inspection book. Q I..ct)',,...-r t;.,;,. f -17 c..,.,_,_,.. ti ~~ "i Cc{N' ~ I v -r/..,!u.l - d- I 12 <-1 I~ Once again this K025 tag was corrected on August 12, Sincerely, Lance Wolfley Maintenance manager Franklin County Medical Center

10 To whom it may concern: This is a (Poe) for deficiencies that were found on July 24,2013. Fork 147 tag, the corrective action will be to pull and relocate electric power cord to its own dedicated receptacle in accordance with NFPA 70, national electric code. By relocating the power cord to a correct receptacle we have identified that there are no other residents having the potential to be affected. There will be a monthly walk thru and inspection. This will be done by the maintenance manager and documented and dated to ensure that the deficiency does not recur. The corrective action will be monitored by the maintenance manager every first week of the month in / the fire inspection book. ~:r ~6".,...-r (;; S"'~ +y (!~.,.,.+t -4. 7'"'-'&,-<.t-\J ~/,._~ '-L tz/ ~ Once again this K147 tag was corrected and fixed on July By Stateline electrical contractors. See attached photo and invoice. Sincerely, Lance Wolfley Maintenance manager Franklin County Medical Center

11 PRINTED: 07/30/2013 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - ENTIRE NF BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER FRANKLIN COUNTY TRANSITIONAL CARE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 44 NORTH 1ST EAST PRESTON, ID ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 07/24/2013 (X5) COMPLETE DATE C INITIAL COMMENTS c 000 The Administrative Rules of the Idaho Department of Health and Welfare, Skilled Nursing and Intermediate Care Facilities are found in IDAPA 16, Title 03, Chapter 2. The facility is a single story type II (111) building with a complete sprinkler system that was installed in July The plans for the building were approved in 1970 and construction completed in There have been subsequent remodels. Currently the facility is licensed for 35 NF beds. The following deficiencies were cited during the annual fire/life safety survey conducted on July 24; The facility was surveyed under IDAPA , Rules, and Minimum Standards for Skilled Nursing and Intermediate Care Facilities. The surveyor conducting the survey was: Tom Mroz CFI-11 Health Facility Surveyor Facility Fire Safety and Construction C FIRE AND LIFE SAFETY c FIRE AND LIFE SAFETY. Buildings on the premises used as facilities shall meet all the requirements of local, state and national codes concerning fire and life safety standards that are applicable to health care facilities. This RULE: is not met as evidenced by: Refer to the following Federal "K" tags on the CMS- 2567: 1. K025 Penetrations 2. K147 Electrical ffi /cj:p LABORATORY DIRECTOR'S OR PROVI -- f~r R~..SlSNATURE t.. TITLE,./ j drtn<4'>'tfo-"'f<v STATE FORM i (X6) DATE -/2-. -J) If continuation sheet 1 of 2

12 PRINTED: 07/30/2013 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 -ENTIRE NF BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER FRANKLIN COUNTY TRANSITIONAL CARE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 44 NORTH 1ST EAST PRESTON, ID i ID C 226 Continued From Page 1 c 226 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 07/24/2013 (X5) COMPLETE DATE If deficiencies are c1ted, an approved plan of correction 1s requjstte to contmued program participation. cc STATE FORM ZLXU If continuation sheet 2 of 2