NY State Tag

Lack of Privacy Curtains in Physical Therapy Room

Briarcliff Manor Center For Rehab And Nursing CareBriarcliff Manor, New York Survey Completed on 03-20-2025

Summary

The facility failed to ensure privacy curtains were provided around each individual treatment area in the Physical Therapy room, as required by Title 10 regulations. During a Life Safety recertification survey, it was observed that the platform table in the new Physical Therapy room lacked a privacy curtain. In an interview conducted at the time of the finding, the Physical Therapy Director confirmed that a privacy curtain was not used.

Plan Of Correction

Plan of Correction: Approved April 10, 2025

I. Immediate Corrective Action:
1. Privacy Curtain in Physical Therapy Room:
- The Director of Maintenance immediately ordered and installed a privacy curtain around the platform table in the Physical Therapy room to ensure compliance with Title 10 standards.

II. Identification of Others:
- All residents have the potential to be affected.
- No additional privacy curtain issues were identified. However, all treatment areas will be monitored for compliance going forward.

III. Systemic Changes:
1. The Director of Maintenance reviewed the Facility Construction and Maintenance Policy to ensure all treatment areas are properly equipped with the necessary privacy measures, including privacy curtains or partitions where applicable.
- A quarterly inspection schedule for six months will be implemented to ensure privacy curtains are installed and maintained in compliance.

IV. Quality Assurance:
1. A monthly audit for six months will be conducted by the Director of Maintenance to ensure privacy curtains remain in place and compliant in all treatment areas. Any corrective actions will be implemented immediately.
2. Results from the monthly audits will be reviewed during the quarterly QAPI meetings.

V. Person Responsible:
- Director of Maintenance

Penalty

No penalty information released