Dumont Center for Rehabilitation and Nursing Care

Based on observation, interview and record review it was determined that the facility did not provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by construction debris and waste products observed in occupied resident rooms and other areas following sprinkler system renovations.
This was noted on one of three resident floors (2nd floor).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Complaint # NY00098136

The findings are:

A complaint investigation was conducted on 3/8/11 at approximately 2:00 PM. This complaint pertained to a renovation project underway on the 1st floor. Conditions unrelated to the complaint, however, were noted on the 2nd floor that was also undergoing renovations. The sprinkler component of this project (which was submitted to the Bureau of Architectural Engineering and Facility Planning in 11/2010 and is pending approval at this time), involved replacement of existing fire sprinkler piping that resulted in multiple ceiling tiles throughout the unit being cut and broken to accommodate the new piping. The breaking of the tiles resulted in rough, broken edges and exposure of the tiles' potentially friable (i.e. crumbling) material. During this visit, bits of ceiling tile, dust, etc. were noted on the floor of various resident rooms (including rooms # 220, 221,225, 226). These conditions were also noted in areas not undergoing sprinkler renovations (e.g. window alcove near nurses' station, south stairs). Residents were reoccupying the rooms at this point. Adequate housekeeping necessary to provide a clean, orderly environment and to limit or prevent resident exposure to construction debris was not in evidence during this onsite investigation.

In an interview at the time, the Administrator stated that this work had been completed approximately 2-3 weeks. However, he was unable to account for the persistence of the debris and why the Housekeeping Department had not addressed this issue.

483.15(h)(2)
10NYCRR 415.29

415.29 Physical Environment

Physical Plant Violation - State Only

NYCRR 710.1(c)(5) Proposals requiring a prior review limited to architectural and engineering matters.
(i)(a) Proposals where total project cost does not exceed $3,000,000, and for which a certificate of need is not otherwise required under this Part, shall be subject to review under Article 28 of the Public Health Law limited to a determination of whether the proposal is consistent with applicable statutes, codes, rules and regulations relating to the structural, architectural, engineering, environmental, safety and sanitary requirement of licensed medical facilities where the proposal relates to the acquisition, relocation, installation or modification of:

(4) heating, ventilating, air conditioning, plumbing, electrical, water supply, fixed dietary, solid waste and/or sewage disposal, and fire protection systems, other than routine maintenance and repairs or routine purchases affecting such systems.

(ii) Requests for approval of proposals described in this paragraph shall be made directly to the Bureau of Architectural and Engineering Review at the central office of the department in Albany. The applicant shall submit such information and documentation as is required to determine the acceptability of the proposal. If the Bureau of Architectural and Engineering Review determines that a proposal complies with all pertinent statutory and regulatory requirements, the director of such bureau shall notify the applicant, in writing, that the proposal is acceptable. If the Bureau of Architectural and Engineering Review determines that the proposal is not acceptable, the director of such bureau shall notify the applicant, in writing, of such determination the basis thereof. if the applicant has not submitted an acceptable proposal within 30 days of such determination, then the proposal shall be deemed an application subject to full review pursuant to section 2802 of the Public Health Law and this Part and shall be submitted to the State Hospital Review and Planning Council and the local health systems agency, with a staff recommendation of disapproval, for their recommendation.

710.7
Approval to start construction. (a) The applicant may seek approval to start construction of the project, or one or more phases thereof, upon the filing with the department completed contract documents consistent with all previous approvals.

(b) If documents are not completed, the applicant may request approval to start construction upon submission of a certification by the applicant, construction manager or contractor, and the architect that completed working drawings and specifications shall be submitted within a time period specified in the applicant's request, that such construction shall be undertaken at the applicant's risk and that approval is understood to be contingent upon submission of the completed documents as a no-cost change order.

(c) A request by the applicant pursuant to subdivision (a) or (b) of this section shall include an affidavit by the applicant's architect or engineer that the drawings:

(1) are consistent with schematic and design development drawings previously approved and, if not, the affidavit shall identify the changes and reasons for such changes; and

(2) are in compliance with the applicable provisions of this Title and all applicable local codes, statutes and regulations. In addition, the applicant shall submit an up-dated functional stack diagram consistent with section 710.2(b)(10)(i)(b) of this Part.

(d) When the submission under subdivision (a) or (b) of this section is deemed complete by the department, the applicant shall be advised in writing to commence construction pursuant to this Part.

This REQUIREMENT is not met as evidenced by:

Based on observations, interviews and documentation review, it was determined that the facility did not ensure that the physical environment was maintained in a safe manner in accordance with State requirements as evidenced by: 1.) sprinkler system renovations that were taking place without the required review and approval by the Bureau of Architectural and Engineering Facility Planning (BAEFP) and without an acceptable safety plan; and 2.) work was not being completed in an orderly, workmanlike manner.
This was noted on one of three resident floors (2nd floor).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Complaint No. NY00098136

Findings are:

THIS IS A REPEAT DEFICIENCY

A complaint investigation was conducted at approximately 2:00 PM on 3/8/2011 regarding renovations on the 1st floor. On 10/14/10, the regional office approved a safety plan for cosmetic renovations on the 1st floor resident units only. The renovations were to include the installation of new wallpaper, flooring, and ceiling tiles. A complaint investigation conducted on 10/24/10 regarding concerns with these renovations revealed that the work observed at the time had exceeded the scope of the approved project and safety plan and was not being done in an orderly, workmanlike manner. Additionally, work on the sprinkler system, i.e. removal of sprinkler pipes and relocation of sprinkler heads, was being done without submittal of the required limited review application and Bureau of Architectural Engineering and Facility Planning (BAEFP) approval, notification of the regional office, or a safety plan. The facility submitted a revised safety plan for the previously approved renovation project that was acceptable, and submitted a limited review application in 11/2010 to BAEFP for the sprinkler project. As of this time, the sprinkler project is under review and pending approval.

During the complaint investigation conducted on 3/8/11 it was observed that sprinkler modifications were continuing to take place prior to BAEFP approval, i.e. existing fire sprinkler piping on the 2nd floor nursing unit had been removed and replaced. This work involved multiple ceiling tiles throughout the unit being cut and broken to accommodate the new piping. Bits of broken ceiling tiles, dust, and construction debris were noted on the floor of several occupied resident rooms (including rooms #220, 221, 225, and 226), as well as in the window alcove near the nurses' station and the south stairwell. In an interview at the time, the Administrator stated that the sprinkler work in the resident rooms on the 2nd floor had been completed approximately 2 to 3 weeks ago. However, he was unable to account for the presence of the construction debris and why the Housekeeping Department had not addressed this issue.

Review of the Statement of Deficiency (SOD) resulting from the 10/24/10 complaint investigation revealed that the State Only I310 deficiency had been cited for numerous issues, including the scope of work exceeding an approved project and safety plan; sprinkler work taking place without a limited review application, BAEFP review and approval, or safety plan; and renovation work being done in a disorderly, non-workmanlike manner.

Review of the corresponding Plan of Correction (POC) revealed that "... construction without an approved safety plan, and/or an approved CON (Certificate of Need project) was stopped pending approval". It also stated that "Daily construction audits would be done throughout the duration of construction by the Director Of Operations to ensure that all work being completed is part of a DOH approved safety plan, ... and to ensure that all work is being done in an orderly, workmanlike manner".

Based on observations made during the current complaint investigation, it was determined that the POC for the deficiency cited for the previous construction related complaint was not effectively implemented and sustained.

NYCRR 710.1, 710.7
10 NYCRR 415.29