Nursing Investigation Results -

Pennsylvania Department of Health
BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA
Inspection Results For:

There are  26 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on January 31, 2019, at Bethlen Home Of The Hungarian Reformed Federation of America, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.





 Plan of Correction:


Initial comments:Name: NEW BUILDING - Component: 03 - Tag: 0000


Facility ID# 021402
Component 03
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 31, 2019, it was determined that Bethlen Home of the Hungarian Reformed Federation of America was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected wood frame building, without a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: NEW BUILDING - Component: 03 - Tag: 0353


Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, in over 100 sprinkler heads inspected.

Findings include:

1. Observation on January 31, 2019, at 10:27 a.m., revealed a sprinkler head loaded with dust in the private dining room, in the 400 wing .

Interview with the Administrator, Maintenance Director, and Administrator in training on January 31, 2019, at 1:00 p.m., confirmed the automatic sprinkler system deficiency.





 Plan of Correction - To be completed: 02/04/2019

The sprinkler head located in the 300 hall dining area has been cleaned. There is no longer dust or debris present on the fixture.
In order to prevent future instances, the Director of Maintenance and Director of Environmental Services will monitor to ensure that all sprinkler heads in the dining areas are free from dust and/or debris.
The plan of correction is complete as of 2/4/2019
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: NEW BUILDING - Component: 03 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls, in two instances, affecting four of seven smoke compartments.

Findings include:

1. Observation on January 31, 2019, revealed the following unsealed smoke barrier wall penetrations:

a) 9:28 a.m., an unsealed pipe and wire penetration above the cross-corridor doors near Food and Nutrition Services in the service corridor.
b) 10:48 a.m., an unsealed wire penetration above the cross-corridor doors near room 301.

Interview with the Administrator, Maintenance Director, and Administrator in training on January 31, 2019, at 1:00 p.m., confirmed the smoke barrier wall deficiencies.








 Plan of Correction - To be completed: 02/05/2019

The areas above the cross-corridor doors near Food and Nutritional Services in the service corridor, and the wire penetration area above the cross-corridor doors near room 301 have been sealed with an approved Fire Barrier Sealant.

The Maintenance Supervisor will perform random audits in order to ensure maintained compliance.
The above plan of correction was completed on 2/5/2019.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: NEW BUILDING - Component: 03 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.

Findings include:

1. Review of documentation on January 31, 2019, at 9:00 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection.

Interview with the Administrator, Maintenance Director, and Administrator in training on January 31, 2019, at 1:00 p.m., confirmed the facility lacked documentation, at the time of the survey, showing that an annual fire door assembly inspection had been completed.





 Plan of Correction - To be completed: 02/04/2019


The annual Fire/smoke door inspection documentation was completed for each fire door.

In order to prevent future instances, the above requirement of fire/smoke door inspection documentation will occur annually as indicated.

Thank you

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