Transcript 10 MOST FREQUENTLY CITED VIOLATIONS Assisted Living Facilities (ALFs) July 2015 Welcome This computer based training (CBT) was designed to inform you about the 10

10 MOST FREQUENTLY CITED
VIOLATIONS
Assisted Living Facilities (ALFs)
July 2015
Welcome
This computer based training (CBT) was designed to
inform you about the 10 most frequently cited violations in
Assisted Living Facilities in Fiscal Year 2014.
Navigation
Click anywhere in the screen to go forward one slide at a
time.
Scroll up to go back.
Click the exit button in the top right hand corner to leave
the program.
Inspection Process
Investigators base their decisions of compliance on the
following documents:
Texas State rules
• Texas Administrative Code, Title 40, Part 1, Chapter 92:
Licensing Standards for Assisted Living Facilities (ALFs)
• Texas Health and Safety, Title 4, Chapter 253: Employee
Misconduct Registry
• Texas Health and Safety Code, Title 4, Chapter 247: ALFs
• Texas Health and Safety Code, Title 4, Chapter 250: Nurse
Aide Registry and Criminal History Checks of Employees
and Applicants for Employment in Certain Facilities of
Employees and Applicants for Employment in Certain
Facilities Serving the Elderly Persons with Disabilities
•
State Rules
The Texas Administrative Code (TAC) chapter 92 contains
the state licensure rules governing ALFs that are enacted
under the authority of the Health Safety Code (HSC)
chapter 247.
Inspectors use the rules in Chapter 92 to determine
whether the facility is in compliance. Citations are based
on noncompliance with the standards.
Inspection Focus
DADS inspects ALFs to determine compliance with
minimum standards.
The inspection team may be just one person.
The inspection process is intended to:
• protect the health and safety and rights of residents; and
• determine compliance with regulations.
Inspection Focus
Violations can include both actual and potential negative
outcomes.
Inspectors determine whether the facilities are in
compliance during the inspection.
Inspection Focus
During the inspection the inspectors assess the facility’s:
• Compliance with residents’ rights requirements;
• Compliance with residents’ quality of life requirements;
• Compliance with residents’ quality of care requirements;
• Accuracy of residents’ comprehensive assessments;
• Adequacy of care plans based on comprehensive
assessments; and
• Effectiveness of the physical environment to empower
residents, accommodate their needs, and maintain
safety.
DADS Annual Report
DADS is required to compile and report inspection and
enforcement data every year. This data is captured in the
Regulatory Services Annual Report.
Part of this report includes the top 10 violations cited during
the fiscal year covered in the report.
DADS Annual Report is available online at:
http://www.dads.state.tx.us/providers/reports/sb190/index.h
tml
DADS Annual Report
This presentation is based on the data contained in the
Regulatory Services FY14 Annual Report which covers the
period of 9/1/13 to 8/31/14.
Other than minor changes in position within the top 10,
eight of the top 10 violations listed in the FY13 annual
report continue to be top 10 issues in FY14.
The top 10 violations in the FY14 annual report are listed in
order from least frequently cited (#10) to most frequently
cited (#1).
Learning Objectives
In this course, you will:
• identify the 10 most frequently cited violations for ALFs;
and;
• evaluate examples of the most frequently cited violations.
Violations Chart for FY14 and FY13
Rank
Tag Number
Tag Title
FY14
FY13
§92.41(c)(2)
Resident Assessment: Service Plan
10
not ranked
§92.41(n)(4)(C)
Infection Control: Employee Tuberculosis Screening
9
not ranked
§92.61(b)(4)(B)
Requirement: Type A and Type B Small Must Comply
with Chapter 33
8
9
§92.62 (f)(1)(E)
FA-SS−Contract to Maintain Alarm System
7
10
§92.62(e)(2)
Construction-Interior Wall and Ceiling Surfaces
6
8
§92.62(h)(8)
Sanitation and Housekeeping−Facility Clean and in
Good Repair
5
7
§92.62(c)(2)
Operations: Fire Drills
4
6
§92.62(f )(1)(A)
FA-SS−Fire Alarm and Sprinkler Systems
3
5
§92.62(f )(2)
Sprinkler Systems
2
2
§92.62(i)(2)
General Safety−Building in Good Repair
1
1
#10: P054
§92.41(c)(2) Resident Assessment: Service Plan
(c) Resident assessment. Within 14 days of admission, a resident
comprehensive assessment and an individual service plan for providing
care, which is based on the comprehensive assessment, must be
completed. The comprehensive assessment must be completed by the
appropriate staff and documented on a form developed by the facility.
When a facility is unable to obtain information required for the
comprehensive assessment, the facility should document its attempts
to obtain the information.
(2) The service plan must be approved and signed by the resident or a
person responsible for the resident's health care decisions. The facility
must provide care according to the service plan. The service plan must
be updated annually and upon a significant change in condition, based
upon an assessment of the resident.
This tag was not ranked in FY13.
#10: P054
§92.41(c)(2) Resident Assessment: Service Plan
Examples of conditions cited might include:
• facility did not have the service plan approved and
signed by the resident or responsible party;
• resident assessments were not updated annually and
when a significant change in condition occurred; or
• not providing care and services based upon the
assessment of the resident.
#10: P054 Example of a Citation
§92.41(c)(2) Resident Assessment: Service Plan
Based on record reviews and interview, it was determined the
facility did not ensure service plans were approved and signed
by the resident and/or a family member or a person responsible
for the residents' health care decisions for four of four residents
(#s1, 2, 3, and 4) whose charts were reviewed.
Findings included:
During the facility's on-site inspection on 04/27/14 at 9:45 a.m.
resident records were reviewed. The results of this review were
as follows:
Resident #1, 2, 3 and 4’s service plans were not signed by the
resident, family members or responsible party.
(continued on next page)
#10: P054 (continued)
§92.41(c)(2) Resident Assessment: Service Plan
The manager was interviewed regarding the residents'
service plans on 08/27/14 at 10:05 AM. She stated she
was unaware the service plans needed to be signed by the
resident and/or a responsible party.
This failure has the potential to result in residents, family
members or residents’ responsible parties not having input
into the care and services provided by the facility. This
could affect all 21 of the facility's residents.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The intent of §92.41(c)(2) Resident Assessment: Service Plan
State Rule is to provide a method for the resident, family
member or a person responsible for the resident's health care
decisions to have input into the care of the resident.
true
false
Activity: True/False
The correct answer is true.
The intent of this State Rule is to provide a method for the
resident, family member or a person responsible for the
resident's health care decisions to have input into the care
of the resident.
#9: P132
§92.41(n)(4)(C) Infection Control: Employee Tuberculosis Screening
(4) The facility must have written policies for the control of
communicable disease in employees and residents, which
includes tuberculosis (TB) screening and provision of a safe
and sanitary environment for residents and employees.
(C) The facility must screen all employees for TB within two
weeks of employment and annually, according to
Centers for Disease Control and Prevention (CDC)*
screening guidelines. All persons who provide services
under an outside resource contract must, upon request of the
facility, provide evidence of compliance with this requirement.
This tag was not ranked in FY13.
• Next slide provides information on CDC. CDC ensures the health of Americans through its system
of health surveillance, preventative action, education and research.
#9: P132 related to CDC’s guidelines
The CDC TB guidelines stress the importance of considering the
community in TB risk assessments. When a provider is screening for
TB in accordance with the CDC TB guidelines or other guidelines, the
provider must maintain documentation of the screenings
• The CDC TB guidelines are available on the CDC TB “Infection
Control & Prevention” webpage at
http://www.cdc.gov/tb/publications/guidelines/infectioncontrol.htm. On
this webpage you will also find a link to the CDC:
• “Additional FAQs for Clarification of Recommendations in the
Guidelines”; and
• “Appendix B Tuberculosis (TB) Risk Assessment Worksheet.” This
worksheet can be used as a guide for conducting a risk assessment.
The results of the risk assessment will determine the extent of each
TB screening.
#9: P132
§92.41(n)(4)(C) Infection Control: Employee Tuberculosis
Screening
The facility did not ensure that all employees providing direct
care services were screened for TB within two weeks of
employment and annually.
Examples might include the following:
• Facility not having a system in place to ensure all direct care
employees are screened for TB.
• Facility not screening direct care employees within two
weeks of employment.
• Facility not screening direct employees annually; and
• Person who provide services under an outside contract
not providing evidence of compliance with TB screening.
#9: P132 Example of a Citation
§92.41(n)(4)(C) Infection Control: Employee Tuberculosis Screening
Based on interview and record reviews, the facility did not provide
evidence that four (#s A, D, G and H) of 12 caregivers were screened
within two weeks of employment and on an annual basis.
Findings included:
Record review on 10/04/14 at 2:15 p.m. of the personnel files for the
four caregivers found the files did not provide documentation for TB
screenings.
Interview with the manager on 10/04/14 at 3:00 p.m. confirmed the fact
that the screening had not been completed for these four employees.
This failure placed all 33 residents at risk of exposure to staff who may
have positive TB tests.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The facility must have written policies for employees and
residents concerning the control of communicable
diseases. The policy must include screening guidelines for
TB within three weeks of employment.
true
false
Activity: True/False
The correct answer is False.
The facility must have written policies for the control of
communicable disease in employees and residents, which
includes TB screening within two weeks of employment .
#8: P219
§92.61(b)(4)(B) Requirement: Type A and Type B Small must
comply with Chapter 33 of the life safety code
(LSC) NFPA 101 2000 edition
(b) Applicability of requirements for construction and life safety.
(4) Buildings and structures must comply with the 2000
edition of NFPA 101, as published by the National
Fire Protection Association, Inc., as follows. For new
construction, DADS may authorize an assisted living facility
to comply with later editions of the code, in their entirety,
when required by local building authorities.
(B) All existing Type A facilities and small Type B facilities
must comply with Chapter 33, Existing Residential Board
and Care Occupancies.
This tag ranked 9th in FY13.
#8: P219
§92.61(b)(4)(B) Requirement: Type A and Type B Small
Must Comply with Chapter 33
The facility must comply with Existing Residential Board
and Care Occupancies.
Examples of conditions might include the facility:
• not providing an exterior exit that was not exposed to the
kitchen, dining and living rooms; or
• not providing a separated protected means of egress
which was not exposed to the kitchen, dining and living
rooms.
#8: P219 Example of a Citation
§92.61(b)(4)(B) Requirement: Type A and Type B Small
Must Comply with Chapter 33
Based on observation and interview, the facility did not provide a
separated, protected means of egress from the bedrooms which was
not exposed to common spaces for four of five bedrooms.
Findings include:
Observation at 9:00 a.m. on 07/02/14 revealed bedrooms 2, 3, 5 and 7
did not have either an exterior exit or a separated, protected means of
egress which was not exposed to the kitchen and living room.
Interview with the manager at 10:30 a.m. on 07/02/14 the manager said
she would request a Fire Safety Evaluation System (FSES) for
equivalent compliance for this violation. FSES provides a level of
safety that equals or exceeds a requirement of Life Safety Code (LSC).
Facilities rely on the FSES in order to comply with the LSC
requirement.
In the event of a fire this failure could expose all 20 residents to smoke
and fire.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
ALFs must provide a separated protected means of egress
from all bedrooms that is not exposed to the kitchen, dining
and living rooms (common spaces).
true
false
Activity: True/False
True is the correct answer.
ALFs must provide a separated protected means of egress
from all bedrooms that are not exposed to the kitchen,
dining and living rooms (common spaces).
#7: P255
§92.62(f )(1)(E) FA-SS-Contract to Maintain Alarm System
(f) Fire alarm and sprinkler system
(E) The facility must have a written contract with a fire alarm firm
which has been issued an Alarm Certificate of Registration (ACR)
number from the Texas State Fire Marshal's Office (TSFMO) to
perform the inspection, test and maintenance requirements of
NFPA 72 semiannual.
This tag ranked 10th FY13.
#7: P255
§92.62(f )(1)(E) FA-SS-Contract to Maintain Alarm
System
The facility did not provide a written contract with a fire
alarm firm to perform inspections, testing, and
maintenance of the system at least every six months
Examples of conditions might include the following:
• facility not having a written contract with a fire alarm
firm to perform inspections, testing, and
maintenance; or
• facility failing to have the fire alarm system inspected
once every six months.
#7: P255 Example of a Citation
§92.62(f )(1)(E) FA-SS-Contract to Maintain Alarm System
Based on record reviews and interview, the facility did not have the fire
alarm system inspected once every six months as required.
Findings include:
Record review at10:15 a.m. on 09/15/15 found the blue inspection tags
inside the fire alarm control panel, reflected the last inspection of the
fire alarm system was on 01/12/14. The licensed company had
inspected the fire alarm system more than six months ago.
Interview with the manager confirmed that the last inspection of the fire
alarm system was on 01/12/14.
This failure could delay detection and notification to staff of a fire in the
event the fire alarm system malfunctioned from lack of routine
inspections. This could effect all 15 residents’ safety, if a fire occurred
at the facility.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The ALF must have inspections, tests and maintenance
stipulated in the contract with the City Fire Marshall’s office.
true
false
Activity: True/False
The correct answer is False.
The ALF must have inspections, tests and maintenance
stipulated in the contract with a fire alarm firm, not City Fire
Marshall’s office.
#6: P240
§92.62(e)(2) Construction-Interior Wall and Ceiling
Surfaces
(e) Construction.
(2) Interior wall and ceiling surfaces must have as the
finished surface or as substrate or sheathing a fire
resistance of not less than that provided by 3/8" gypsum
board (20 minute fire rating), unless approved otherwise by
DADS. A sprinkler system will not substitute for the minimum
construction requirements. Exceptions are existing Type B
large facilities must meet the construction requirements of
NFPA 101, Chapter 19.1.6.
This tag ranked 8th in FY13.
#6: P240
§92.62(e)(2) Construction-Interior Wall and Ceiling
Surfaces
The facility did not ensure that interior walls and/or
ceilings were constructed with a material having at
least a 20-minute fire rating, or at least 3/8 gypsum
board.
Examples of conditions might include the following:
• facility failing to ensure that interior walls and/or
ceilings were constructed with a material having at
least a 20-minute fire rating; or
• facility failing to ensure that walls and ceiling are
constructed with at least 3/8 inch gypsum board.
#6: P240 Example of a Citation
§92.62(e)(2) Construction-Interior Wall and Ceiling
Surfaces
Based on observations and interview the facility did not ensure
interior walls and ceilings were constructed with a material
having at least a 20-minute fire rating, or at least 3/8 gypsum
board. Observations made on 05/12/14 at 9:45 a.m. revealed
that there were areas in the facility that were not constructed
with a material that had at least a 20-minute fire rating and did
not have a covering of 3/8 gypsum board. The areas were:
a) The plywood cover on the pull-down attic; and
b) The fireplace opening in the living room.
These failures could allow a fire to spread into the attic space
due to lack of fire rated separation. This could cause potential
injuries or death to the 38 residents in the event of a fire.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The facility must ensure interior walls and/or ceilings are
constructed with a material that has at least a 30-minute
fire rating or has at least 3/8 gypsum board applied to the
walls and/or ceilings.
true
false
Activity: True/False
The correct answer is False.
The facility must ensure interior walls and/or ceilings are
constructed with a material that has at least a 20 minute,
not a 30-minute, fire rating or has at least 3/8 gypsum
board applied to the walls and/or ceilings.
#5: P179
§92.62(h)(8) Sanitation and Housekeeping-Facility Clean
and in Good Repair
(h) Sanitation and housekeeping
(8) The facility must be kept free of accumulations of dirt,
rubbish, dust, and hazards. Floors must be maintained
in good condition and cleaned regularly. Walls and
ceilings must be structurally maintained, repaired, and
repainted or cleaned as needed. Storage areas and
cellars must be kept in an organized manner. No
storage will be permitted in the attic spaces.
This tag ranked 7th in FY13.
#5: P279
§92.62(h)(8) Sanitation and Housekeeping-Facility Clean
and in Good Repair
The facility failed to maintain the building free of
accumulations of dirt, rubbish, dust and hazards.
Examples of conditions might include the following:
• carpet in living room buckled
• walls, doors and door frames soiled, dirty or scraped
• linens, clothing, lint and dust behind the laundry washer
• windows, blinds and window sills covered with soil, dirt
and dust
• kitchen hood and cabinets soiled, covered with food
splatters inside and outside.
#5: P279 Example of a Citation
§92.62(h)(8) Sanitation and Housekeeping-Facility Clean
and in Good Repair
Based on observations and interview the facility did not maintain
the building free of accumulations of dirt, rubbish, dust, and
hazards. Observation made on 01/21/14 between 9:30 and
10:45 a.m. revealed the following:
• bedroom #s 4 and 7 had dirty windows missing window slats;
• living room furniture had worn areas and a urine odor;
• several kitchen cabinets had dirt and grease; and
• oven had food particles and grease on it.
Interview on 01/21/14 at 11:15 a.m. with the manager it was
revealed that the facility did not have a sufficient number of
maintenance people to keep the facility in good repair.
These failures could affect the quality of life for all 31 residents.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The facility must ensure that staff members keep the
building cleaned, sanitized and in good repair to promote
good quality of life for residents.
true
false
Activity: True/False
True is the correct answer.
The facility must ensure that staff members keep the
building cleaned, sanitized and in good repair to promote
good quality of life for residents.
#4: P234
§92.62(c)(2) Operations: Fire Drills
(a) General
(2) Fire drills must be conducted quarterly on each shift
and with at least one drill conducted each month.
The drills may be announced in advance to the
residents. The drills must involve the participation of
the staff in accordance with the emergency plan.
Residents must be informed of evacuation
procedures and locations of exits. All fire drills must
be documented on a form provided by DADS. In
large Type B facilities, the drill must include the
activation of the fire alarm signal.
This tag ranked 6th in FY13.
#4: P234
§92.62(c)(2) Operations: Fire Drills
The facility did not ensure fire drills were conducted and
documented to be in compliance with licensing standards.
Examples of conditions could include:
• facility not conducting fire drills and documenting the
drills; or
• facility did not ensure fire drills were performed at least
quarterly on each shift, with one drill done each month.
#4: P234 Example of a Citation
§92.62(c)(2) Operations: Fire Drills
Based on record review and interview, the facility did not
ensure that fire drills were conducted quarterly on each
shift and with at least one drill conducted each month, by
not ensuring that fire drills were conducted for 9 of 12
months reviewed (March-November).
Findings Include:
Record review of the fire drill records revealed there was
no documentation on fire drills during the period of March
through November.
(continued on next page)
#4: P234 (continued)
§92.62(c)(2) Operations: Fire Drills
Interview with the maintenance supervisor on 11/30/14
confirmed the fire drills were missing from the facility’s log
book.
This violation has the potential to expose all 15 residents to
staff members, who were unaware of procedures to follow
in an emergency.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
To meet this requirement the facility must conduct monthly
fire drills on each shift and document the date and time.
true
false
Activity: True/False
The correct answer is False.
The facility must conduct fire drills quarterly on each shift
(not monthly). The requirement is at least one drill
conducted each month.
#3: P249
§92.62(f) (1)(A) FA-SS-Fire Alarm and Sprinkler Systems
f) Fire alarm and sprinkler systems.
(1) Fire alarm and smoke detection system. An ALF must install
an underwriter's laboratory (U.L.) listed manual fire alarm
initiating system, with an interconnected automatic smoke
detection and alarm initiation system. The operation of any alarm
initiating device must activate an audible or visual alarm at the site.
(A) Smoke detectors must be installed in resident bedrooms,
corridors, hallways, living rooms, dining rooms, offices,
and public or common areas. Kitchens, laundries, and
attached garages used for car parking may have heat
detectors in lieu of smoke detectors.
This tag ranked 5th in FY13.
#3: P249
§92.62(f) (1)(A) FA-SS-Fire Alarm and Sprinkler Systems
The facility did not ensure that the fire alarm and smoke
detection system was in compliance with licensing
standards.
Examples of conditions include:
• facility not having an interconnected automatic smoke
detection and alarm initiation system;
• facility not having an alarm initiating device that is
activated by an audible or visual alarm on site; and
• facility not having smoke detectors installed in resident
bedrooms, hallways, living rooms, dining rooms and
offices.
#3: P249
§92.62(f) (1)(A) FA-SS-Fire Alarm and Sprinkler Systems
Based on observations and interview, the facility did not
maintain the fire alarm system in a working condition.
Findings include:
Observation at 8:45 a.m. on 02/15/15 revealed the fire
alarm control panel indicated an amber warning light. The
panel indicated a "trouble" condition. The display reflected
"dirty smoke sensor.“
Observation at 8:55 a.m. on 02/10/15, the manager
manually reset the fire alarm control panel. The panel failed
to reset and returned to the same "trouble" condition. The
manager then silenced the audible trouble alarm.
#3: P249 (continued)
§92.62(f) (1)(A) FA-SS-Fire Alarm and Sprinkler Systems
Observation at 9:15 a.m. on 02/15/15 revealed the handle
on the fire alarm manual pull at the exterior exit door would
not pull down to activate a general fire alarm. The handle
was binding and would not move down.
Interview at 9:30 a.m. on 02/10/15 the manager said that
whenever this has happened in the past, “the company
calls and we reset the panel.” The manager stated she
would call the fire alarm company.
This failure could delay notification of a fire to occupants of
the building and could affect all 25 residents.
Activity: #3 Multiple Choice
Directions: Select the answer that is incorrect.
A facility’s Fire Alarm and Sprinkler system must:
A. install manual fire alarm initiating system;
B. have an interconnected automatic smoke detection and
alarm initiation system;
C. have an initiating device that does not activate an audible or
visual alarm at the site.
D. include smoke detectors installed in resident bedrooms,
hallways, living rooms, dining rooms, offices and public or
common areas.
Activity: Multiple Choice
C is the correct answer.
The facility’s fire alarm and sprinkler system does have to
have an initiating device to activate an audible or visual
alarm at the site.
#2: P259
§92.62(f )(2) Sprinkler Systems
(f) Fire and sprinkler systems
2) Sprinkler systems. When installed or required, sprinkler systems
must be inspected, tested, and maintained in accordance
with NFPA 25. The facility must have a written contract with a fire
protection sprinkler firm that has been issued a Sprinkler
Certificate of Registration number (SCR) from the Texas State Fire
Marshal's Office (TSFMO) to perform the required services semiannually.
The facility must have documentation available to show that all the
requirements of NFPA 25 have been met including the annual
inspection, test and maintenance by the registered fire sprinkler
firm. Additionally, the facility must have an Alarm Certificate of
Registration (ACR) number from the TSFMO to perform the inspection,
test and maintenance requirements of NFPA 72 semiannually.
This tag also ranked 2nd in FY13.
#2: P259
§92.62(f )(2) Sprinkler Systems
The facility did not ensure the required sprinkler system
was inspected, tested and maintained in compliance with
National Fire Protection Association (NFPA) 25.
Examples could include the facility not having:
• the facility’s sprinkler system inspected, tested and
maintained;
• a written contract with a fire protection sprinkler firm;
• performing the required services semiannually; or
• documentation to show that requirements have been
met.
#2: P259
§92.62(f )(2) Sprinkler Systems
Based on observations, record review and interview the
facility did not ensure the required sprinkler system was
inspected, tested and maintained in compliance with NFPA
25.
Record review on 07/25/14 at 8:30 am revealed the facility
did not have available a service contract for semiannual
inspection of the fire sprinkler system.
Interview on 07/25/14 at 11:20 am with the manager,
revealed that he did not know about these requirements.
These failures could result in failure to detect a malfunction
in the sprinkler system due to lack of service and has the
potential to affect 33 residents.
Activity: Multiple Choice
Directions: Select the answer that is incorrect.
The facility must have the following information regarding the fire alarm
and sprinkler system.
A. The facility must have a written contract with a fire protection
sprinkler firm.
B. The facility must have documentation available to show that all the
requirements have been met; this does not include an annual
inspection, test and maintenance of the system.
C. The facility must have the required services performed
semiannually.
D. The facility needs a service contract for semiannual inspection of
the fire sprinkler system.
Activity: Multiple Choice
B is the correct answer. The facility must have
documentation available to show that all the requirements
have been met; this does include an annual inspection,
testing and maintenance of the system.
#1: P285
§92.62(i)(2) General Safety-Building in Good Repair
(i) General safety features.
(2) The building must be kept in good repair. Electrical,
heating, and cooling systems must be maintained in
a safe manner. DADS may require the facility
sponsor or licensee to submit evidence to this effect,
consisting of a report from the fire marshal, city or
county building official having jurisdiction over the
location of the facility, licensed electrician, or a
registered professional engineer. Use of electrical
appliances, devices, and lamps must not overload
circuits or cause excessive lengths of extension
cords.
This tag also ranked 1st in FY13.
#1: P285
§92.62(i)(2) General Safety-Building in Good Repair
The facility failed to ensure that the building was kept in good
repair.
Examples of conditions might include the following:
• limbs of trees laying on the power line in the yard of the
building;
• ground-fault circuit-interrupter protection (GFCI) not provided in
the kitchen;
• GFCI located in the restroom not tripping the circuit when
tested; or
• a loose electrical outlet with extension cord in use.
#1: P285 Example of a Citation
§92.62(i)(2) General Safety-Building in Good Repair
Based on observation, testing and interview the facility did not
ensure the home was being maintained in good repair.
Findings Include:
Observation on 02/24/15 at 10:45am revealed two multi-plug
adapters in use in resident room #10. There were four
appliances in use at each multi-plug adapter at the time of
observation. Observation also revealed a loose electrical outlet
in room #6 and an adapter with an extension cord.
Interview on 02/24/15 with the Manager, she confirmed the
electrical issues identified.
These failures could affect the safety of all residents if the home
is not maintained free of potential electrical hazards that could
cause an electrical fire to start.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
One of the intents of this State Rule is to ensure the use of
electrical appliances, devices and lamps do not cause
overloaded circuits.
true
false
Activity: True/False
True is the correct answer.
One of the intents of this rule is to ensure the use of
electrical appliances, devices and lamps do not cause
overloaded circuits.
Correcting Violations
The facility needs to:
• analyze the problem by asking what happened and why
did it happen;
• address the problem by developing and implementing a
Plan of Correction; and
• improve systems to ensure lasting correction to the
problems.
Conclusion
These Top 10 violations tend to remain on Top 10 lists
because they involve key facility systems, such as resident
assessment, infection control, life safety and building
maintenance and repair. These are areas that involve the
interaction of many different staff in multiple departments.
The expectation is that the facility will analyze the problem
with the goal of developing a lasting solution. This requires
the facility to understand the cause of the problem and
whether the problem is linked to a failure in the facility’s
system(s).
Conclusion (continued)
The facility can devise an appropriate and lasting solution
to correct any existing or potential problems.
Substantial compliance can be achieved and maintained by
understanding State Rules and implementing them into
practice. The facility must consistently monitor its practices
and make adjustments as necessary.
DADS Websites
This is DADS home page—
www.dads.state.tx.us
DADS provides joint trainings. The Joint Training website
contains the current schedule and a description of each
course. These courses provide continuing education for
some disciplines.
Joint Training Seminars—
www.dads.state.tx.us/providers/training/jointtraining.cfm
Contact
If you have questions or need additional information,
contact:
DADS Regulatory Services
Policy, Rules and Curriculum Development
512-438-3161
Ask for an ALF program specialist.