Nursing Investigation Results -

Pennsylvania Department of Health
FELLOWSHIP MANOR
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FELLOWSHIP MANOR
Inspection Results For:

There are  32 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.
FELLOWSHIP MANOR - 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 March 19, 2019, at Fellowship Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID # 063102
Component 01
Building 01

Based on a Medicare/Medicaid Recertification Survey completed on March 19, 2019, it was determined that Fellowship Manor 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 two-story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review and interview it was determined that the facilty failed to install carbon monoxide detectors per PA Act # 45, on one of one systems.

Findings include:

1. Interview on March 19, 2019, at 8:35 a.m., revealed at the time of survey, the facility was unable to verify that the carbon monoxide detectors, that are tied into the fire alarm system, had a unique signal allowing staff to differentiate between a carbon monoxide alert and a fire alarm alert.

Interview with the vice president of facility engineering on March 19, 2019, at 8:35 a.m., confirmed the facility was unable to verify that the carbon monoxide detectors, that are tied into the fire alarm system, had a unique signal allowing staff to differentiate between a carbon monoxide alert and a fire alarm alert.

2. Document review on March 19, 2019, at 10:00 a.m., revealed the facility lacked a carbon monoxide policy to include staff response in the event a carbon monoxide alarm was activated.

Interview with the vice president of facility engineering and the human resources and risk manager on March 19, 2019, at 10:00 a.m., confirmed the facility lacked a carbon monoxide policy to include staff response in the event a carbon monoxide alarm was activated.




 Plan of Correction - To be completed: 03/28/2019

On 3/21/2019 it was verified that the carbon monoxide detectors are displayed as "supervisory alarms" only. A newly written and approved Carbon Monoxide Detector Policy includes how the CO detectors alarms are displayed and gives the staff the instructions to follow in the event the Carbon monoxide detector activates. The policy directs staff to notify maintenance immediately. Action will then be initiated to determine the source of the CO and evacuation and /or remediation will be initiated. The policy was circulated to all staff on March 28, 2019.
NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview it was determined that the facility failed to inspect and maintain stairways and smoke proof enclosures in accordance with NFPA 101, 7.2, on one of nine stairway levels.

Findings include:

Observation on March 19, 2019, at 10:55 a.m., revealed the first floor, north stairway, on the corridor side, had a ten inch section of spray on fire proofing missing on the structural beam located above the stairway door, above the lay-in ceiling.

Interview with the vice president of facility engineering on March 19, 2019, at 10:55 a.m., confirmed the first floor north stairway, on the corridor side, had a ten inch section of spray on fire proofing missing on the structural beam located above the stairway door, above the lay-in ceiling.




 Plan of Correction - To be completed: 04/12/2019

The structural beam located above the stairway door, above the lay-in ceiling, will be encapsulated using 2 layers of drywall to provide a 1-hour fire rating. Any reaming gaps will be sealed with in-tumescent sealant This project will be completed by April 12. 2019
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview it was determined that the facility failed to inspect and maintain hazardous area enclosures, on one of three levels.

Findings include:

Observation on March 19, 2019, at 11:59 a.m., revealed the basement dietary store room had a penetration on the back wall sealed with orange spray foam, around cooler refrigerant supply lines.

Interview with the vice president of facility engineering confirmed the basement dietary store room had a penetration on the back wall sealed with orange spray foam, around cooler refrigerant supply lines.




 Plan of Correction - To be completed: 03/25/2019

The orange spray foam around the refrigerant supply lines on the back wall of the basement dietary store room was removed and the penetration was sealed with an approved in-tumescent sealant on March 25, 2019
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview it was determined that the facility failed to inspect and maintain the automatic sprinkler system, on one of three levels.

Findings include:

Observation on March 19, 2019, at 10:52 a.m., revealed the first floor corridor, by room #120, had two lay-in ceiling assembly support wires attached to the sprinkler support brackets, above the lay-in ceiling.

Interview with the vice president of facility engineering on March 19, 2019, at 10:52 a.m., confirmed the first floor corridor, by room #120, had two lay-in ceiling assembly support wires attached to the sprinkler support brackets, above the lay-in ceiling.




 Plan of Correction - To be completed: 03/19/2019

The two lay-in ceiling assembly support wires attached to the sprinkler support brackets above the lay-in ceiling were removed and re- attached to newly installed beam clamps on March 19, 2019.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview it was determined that the facility failed to inspect and maintain electrical power cords and extension cords, on one of three levels.

Findings include:

1. Observation on March 19, 2019, between 11:59 a.m. and 12:01 p.m., revealed the following:
A. (11:59 a.m.) basement central supply office had a surge protector plugged into a surge protector located below the office desk.
B. (12:01 p.m.) basement central supply office had a refrigerator plugged into a surge protector.

Interview with the vice president of facility engineering on March 19, 2019, at 12:01 p.m., confirmed the surge protector deficiencies listed above existed.



 Plan of Correction - To be completed: 03/19/2019

A. The surge protector that was plugged into another surge protector was removed and plugged into a separate wall outlet on 3/19/2019. St
B. The refrigerator plugged into a surge protector was unplugged and re plugged into a wall receptacle on 3/19/2019. The Staff in Central Supply were educated on proper use of surge protectors
Going forward a concentrated effort will be made to inspect office areas for proper use of surge protectors. Any issues identified will be addressed immediately. Any issues identified will be reported at the monthly Safety Committee meeting.

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