This week on the CMSCG Blog, we are reviewing two more Ftags that are part of the Physical Environment regulatory group, F923 Ventilation and F924 Corridors Have Firmly Secured Handrails.
This regulation requires that facilities “have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two.” A lack of ventilation can result in odors and other issues that may be easily observable to surveyors. Facilities have been cited under this Ftag for multiple issues, such as:
- Lack of ventilation in a laundry room where the floor was observed to be covered in a “blackened substance with visible thick, white and gray furry matter” due to no windows or air returns in the room
- Excessive build-up of cigarette smoke in a facility’s main dining room since residents were smoking in there rather than in the designated outdoor area. Staff and residents were seen wearing surgical masks while the residents were smoking.
- Inadequate measures to ensure cigarette smoke from residents smoking outdoors did not get into the building. Surveyors observed on multiple days/times the odor of cigarette smoke in the dining room.
- Improperly functioning bathroom ventilation systems. This has been cited in individual resident rooms, unit shower rooms and in shared lavatory spaces.
F924 Corridors Have Firmly Secured Handrails
This regulation, much like its title suggests, requires that corridors are equipped with firmly secured (affixed to the wall) handrails on each side. Surveyors are instructed to check if all the corridors have handrails, and that those handrails are firmly secured and affixed to the walls. Much like how deficient practices under F923 are cited, issues in this area are identified by surveyor observation. As surveyors are moving through the facility, they will notice if handrails are loose, missing or broken and then issue a citation under F924. If you haven’t seen a surveyor prowling the halls and shaking the handrails as he/she goes, you’ve missed an interesting sight. Remember, it is not necessarily a sanitarian who identifies a loose handrail. Also beware of the pitfall of not ensuring that handrails are re-affixed to the walls following renovations, especially if you have changed the design in the hall and you do not have handrails the entire length of the hall. What happened to that 12” section as you turn into the lounge?
Citations under both F923 Ventilation and F924 Corridors Have Firmly Secured Handrails are easily preventable with a good preventative maintenance program and a functioning maintenance request logging system. When staff are doing environmental rounds, they should be looking for these issues, or if they observe unusual smells/odors, ensure they are reported so they can be addressed. Many of the citations given in these areas also note that the facilities did not have a specific plan in place for routinely checking to ensure everything was functioning as expected or to ensure identified issues were addressed timely.