Huntington Hills Center for Health and Rehabilitation

Deficiency Details, Certification Survey, November 2, 2010

PFI: 7786
Regional Office: MARO--Long Island sub-office

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F500 483.75(h): USE OF OUTSIDE PROFESSIONAL RESOURCES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: November 11, 2010

If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (h)(2) of this section. Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and the timeliness of the services.

Citation date: November 2, 2010

Based on record review and staff interviews during the recertification survey, the facility did not ensure that information requested by a Dialysis Center on four different occasions was provided timely for one of three residents reviewed for dialysis in a total sample of thirty. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. (Resident #13)

The finding is:

Resident #13 has diagnoses that include End Stage Renal Disease and receives Kidney Dialysis three times a week.

The Dialysis Service composition book that was utilized for communication between the facility and the Dialysis Center revealed the following for Resident #13:

1) 9/14/10 The Dialysis Center Dietician documented that she needed a 24 hour diet recall (a resident's food and fluid intake for twenty-four hours/calorie count).

2) 10/12/10 The Dialysis Center Dietician's note stated, "can I please have a calorie count (refer to note on 9/14/10)."

3) 10/19/10 The Dialysis Center Dietician's note stated, "I'm a bit frustrated what does it take for me to get a calorie count. Please see previous requests."

4) 10/26/10 The Dialysis Center Dietician's note stated, "I have been asking for several weeks for a calorie count. So far nothing. This is my third note please share note with Dietician. I did ask her a while back via phone. Please have supervisor call me. This is unacceptable!!"

The Registered Nurse (RN) Charge Nurse was interviewed on 11/1/10 at 11:15 AM and stated that she reviews the Dialysis Composition book daily and thought the resident's Dietician was forwarding the information to the Dialysis Center.

The resident's Dietician was interviewed on 11/1/10 at 11:30 AM and stated that she should have sent the information to the Dialysis Center.

The Dialysis Center Dietician was interviewed on 11/1/10 at 2:30 PM and stated that she needed the detailed information from the calorie count to complete her assessment for the resident.

The Director of Nursing (DON) was interviewed on 11/3/10 at 1:45 PM and stated that the information should be available for both the facility and the Dialysis Center.

415.26(e)(i-iv)

K12 NFPA 101: CONSTRUCTION TYPE

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: Not Available

Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

Citation date: November 2, 2010


The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed.

Please indicate if the facility wishes that waiver(s) to be continued.

Time Limited Waiver - expires on date in which CMS regulations requiring all nursing homes to be fully sprinklered takes effect.

Automatic sprinklers are required under canopies that are not constructed of non-combustible materials and in which combustible materials are used and stored. Example is the exterior canopy on the 2nd floor outdoor lounge/resident smoking area.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-3.1.1, 8-2.5, 8-2.5.5.

K72 NFPA 101: FURNISHING AND DECORATIONS

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: Not Available

Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

Citation date: November 2, 2010


The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed.

Please indicate if the facility wishes that waiver(s) to be continued.

Two sets of exit access doors in the 1D Alzheimers unit were painted to look like wooden shelves with books and wooden cabinetry.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-2.1, 7-1.10.1, 7-1.10.2.1.

K20 NFPA 101: STAIRWAY ENCLOSURES AND VERTICAL SHAFTS

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: Not Available

Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5.6. 19.3.1.1.

Citation date: November 2, 2010


The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed.

Please indicate if the facility wishes that waiver(s) to be continued.

An unprotected vertical opening (i.e. an open staircase) was found between the first and second floors. The design of this vertical opening does not meet all of the requirements of an atrium, or all of the requirements for a mezzanine, or other approved opening.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-3.1.1, 8-2.5, 8-2.5.5.