Nursing Investigation Results -

Pennsylvania Department of Health
MULBERRY HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MULBERRY HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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MULBERRY HEALTHCARE AND REHABILITATION CENTER - 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 April 25, 2019, it was determined that Mulberry Healthcare And Rehabilitation Center, had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(b)(1) REQUIREMENT Subsistence Needs for Staff and Patients:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
[(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Document review on April 25, 2019, at 8:30 a.m., revealed the facility lacked an Emergency Preparedness Plan that included:
a. Subsistence needs for staff and patients (specifically safe storage of food and pharmaceuticals).
b. Sewage and waste disposal.

If the above is not able to be maintained throughout an emergency, an evacuation would have to occur at that time.

Interview with the maintenance director on April 25, 2019, at 8:30 a.m., confirmed the Emergency Preparedness Plan did not include the above elements.




 Plan of Correction - To be completed: 06/11/2019

Proper documentation for, needs for subsistence needs, for staff and patients was started immediately. Provided education by regional director of operations on requirements for emergency preparedness manual. Audits will be complete to ensure compliance.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Faciltiy ID # 021802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 25, 2019, it was determined that Mulberry Healthcare and Rehabilitation Center, was not in compliance with the following requirements of the Life Safety Code for 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 (000), unprotected, wood frame building, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined that the facility failed to conduct fire drills for two of twelve required fire drills.

Findings include:

1. Document review on April 25, 2019, at 8:05 a.m., revealed that the facility lacked documentation that fire drills were conducted for the first and second shifts during the third quarter (July-September) of 2018.

Interview withe the maintenance director on April 25, 2019, at 8:05 a.m., confirmed that the facility lacked documentation that fire drills were conducted for the first and second shifts during the third quarter (July-September) of 2018.






 Plan of Correction - To be completed: 06/11/2019

Maintenance Director will be educated by administrator or designee on proper fire drill practices. Education will include National Fire Protection Association 101 Standard Fire Drills. Audits will be conducted by Administrator or designee for 3 months. Results of audits will be provided to the QAPI committee for further review and recommendations

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