Nursing Investigation Results -

Pennsylvania Department of Health
FREY VILLAGE
Building Inspection Results

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FREY VILLAGE
Inspection Results For:

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FREY VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on a Revisit to an Emergency Preparedness Survey completed on April 22, 2019, it was determined that Frey Village was not in compliance with the requirements of 42 CFR 483.73.



 Plan of Correction:


483.73 REQUIREMENT Establishment of the Emergency Program (EP):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.
The [facility, except for Transplant Center] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements:

*[For hospitals at 482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

*[For CAHs at 485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach.
Observations:
Name: - Component: -- - Tag: 0001

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness program, affecting the entire facility.

Findings include:

1. Review of documentation on April 22, 2019, at 10:30 AM revealed the facility failed to establish and maintain a comprehensive emergency preparedness program, in accordance with 42 CFR 483.73, to include the following standards:

(c) Communication Plan;
(f) Integrated Healthcare Systems.

Interview with the Administrator and the Maintenance Director on April 22, 2019, at 1:30 PM confirmed the facility failed to establish an emergency preparedness plan, required to be in-place by November 15, 2017.
______________________________________________________________________

*Review of documentation, during a revisit survey, on June 10, 2019, at 8:30 AM revealed the emergency preparedness deficiency was not corrected.

Interview with the Maintenance Director on June 10, 2019, at 8:30 AM confirmed the emergency preparedness deficiency was not corrected.




 Plan of Correction - To be completed: 06/24/2019

1. A communication plan was initiated to include education to staff, what to do in the case of phone interruption and how we will communicate to family and staff.
2. The communication plan will be reviewed by NHA/designee monthly for 12 months for changes to communication methods and updates to communication plan.

1. Integrated Healthcare systems. NHA has initiated membership to Pa Healthcare Coalition and will be attending meetings to network with other healthcare systems in the south central region.
2. The
Initial comments:Name: LINCOLN - Component: 01 - Tag: 0000


Facility ID #062102
Component 01
Lincoln Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on April 22, 2019, it was determined that Frey Village was in substantial compliance with the 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 II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: ROOSEVELT - Component: 02 - Tag: 0000


Facility ID #062102
Component 02
Roosevelt Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on April 22, 2019, it was determined that Frey Village was in substantial compliance with the 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 II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.




 Plan of Correction:


Initial comments:Name: TOWER - Component: 04 - Tag: 0000


Facility ID #062102
Component 04
Tower Building

Based on a Medicare/Medicaid Recertification Survey completed on April 22, 2019, at Frey Village, it was determined there were no deficiencies identified under the 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 an eight-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.



 Plan of Correction:


Initial comments:Name: PT/OT ADDITION - Component: 05 - Tag: 0000


Facility ID #062102
Component 05
P T Addition

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on April 22, 2019, it was determined that Frey Village was in substantial compliance with the 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 II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:



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