Nursing Investigation Results -

Pennsylvania Department of Health
GUY AND MARY FELT MANOR, INC.
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GUY AND MARY FELT MANOR, INC.
Inspection Results For:

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GUY AND MARY FELT MANOR, INC. - 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 February 21, 2019, it was determined that Guy And Mary Felt Manor, Inc., 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 February 21, 2019, at 10:00 a.m., revealed the facility lacked an Emergency Preparedness Plan that included subsistence needs for staff and patients (including safe storage of food, water, medical supplies, sewage and waste).

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

Interview with the administrator on February 21, 2019, at 10:00 a.m., confirmed the Emergency Preparedness Plan did not include the above elements.







 Plan of Correction - To be completed: 04/01/2019

The facility has obtained transfer agreements to address the provision of subsistence needs for staff and residents regarding food, water, medical and pharmaceutical supplies, sewage and waste. The Emergency preparedness plan will be updated. The QA committee will review the emergency preparedness plan annually.
483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with 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.
[(c) The [LTC facility and ICF/IID] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

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 February 21, 2019, at 10:15 a.m., revealed the facility lacked an Emergency Preparedness Plan that included sharing plan information with residents' families or representatives.

Interview with the administrator on February 21, 2019, at 10:15 a.m., confirmed the Emergency Preparedness Plan did not include the above element.





 Plan of Correction - To be completed: 04/01/2019

The facility will provide a letter to all current residents informing them of the facility emergency preparedness plan. Thereafter, the facility will provide all newly admitted residents emergency preparedness information upon admission. The facility will also place a statement on their web page regarding their emergency preparedness plan. The QA committee will review the Emergency preparedness plan annually.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID # 072702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2019, it was determined that Guy And Mary Felt Manor, Inc., 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 (111), protected, noncombustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, the facility failed to maintain means of egress, free of all obstructions to full use in case of emergency, at three of seven exits.

Findings include:

1. Observation on February 21, 2019, between 8:45 a.m., and 11:20 a.m., revealed the following exit obstructions:
a. (8:45 a.m.) First floor, Independent Living side, exit discharge sidewalks were ice-covered.
b. (11:20 a.m.) First floor, chart rack, installed in the corridor, near B1 shower room, was not retractable, and created a corridor obstruction when in the open position.

Interview with the maintenance assistant on February 21, 2019, at 11:20 a.m., confirmed the above exit obstructions.










 Plan of Correction - To be completed: 02/27/2019

a) Maintenance or designated staff will ensure that removal of snow and ice is performed in a timely manner.
b) First floor, computer rack near B1 shower room has been removed from the wall on 2/26/19.
QA committee will oversee to ensure compliance monthly.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
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, the facility failed to maintain hazardous areas on one of one patient-care floor.

Findings include:

1. Observation on February 21, 2019, between 11:00 a.m., and 10:45 a.m., revealed the facility changed the use of the following rooms, without State Plan Review approval, or a granted occupancy from the Division of Life Safety, resulting in functional issues:
a. (11:00 a.m.) First floor, soiled utility room (across from skilled room 18), was converted to an oxygen storage room, and combustible items were within five feet of the cylinders.
b. (10:45 a.m.) First floor, administrative storage room, was converted to an office, and the door (equipped with a self-closure for storage), was wedged with an unauthorized hold-open device.

Interview with the maintenance assistant on February 21, 2019, at 10:45 a.m., confirmed the change in use, for the above locations, was not submitted to State Plan Review, and an occupancy from Life Safety was not granted.






 Plan of Correction - To be completed: 04/01/2019

1. The facility will move the oxygen cylinders back to its original location; therefore, not changing the use of rooms. QA committee will oversee compliance is established.
2. The facility will submit plans to the State Plan Review to change the use of the administrative storage room to an office. QA committee will oversee to ensure compliance.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 document review and interview, the facility failed to maintain fire sprinkler systems for one of one sprinkler system.

Findings include:

1. Document review on February 21, 2019, at 9:30 a.m., revealed the facility lacked the most recent quarterly fire sprinkler flow alarm test (December 21, 2018) that indicated the detailed component test results.

Interview with the administrator on February 21, 2019, at 9:30 a.m., confirmed the above sprinkler documentation was not available at the time of the survey.




 Plan of Correction - To be completed: 02/27/2019

Facility received a copy of the quarterly sprinkler test that was performed on 12/21/18. Facility will request that Flame Away Inspection Services provide the facility with documentation in a timely manner. NHA will ensure following an inspection, that the required documentation is received. QA committee will oversee to ensure compliance.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, the facility failed to maintain smoke barriers at one of two smoke barriers.

Findings include:

1. Observation on February 21, 2019, at 10:50 a.m., revealed an unsealed conduit penetration (around and inside the two-inch conduit), in the smoke barrier wall, above the cross corridor doors (near room 21).

Interview with the maintenance assistant on February 21, 2019, at 10:50 a.m., confirmed the above unsealed conduit penetration in the smoke barrier wall.








 Plan of Correction - To be completed: 02/26/2019

Maintenance used Approved fire caulk to unsealed conduit penetration in the smoke carrier wall near room 21. QA committee will oversee to ensure compliance.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain emergency generator testing documentation for one of one emergency generator.

Findings include:

1. Document review on February 21, 2019, at 9:45 a.m., revealed the facility lacked an annual generator inspection (verification the generator meets manufacturer's specifications) within the last year. Last annual inspection was January 30, 2018.

Interview with the administrator on February 21, 2019, at 9:45 a.m., confirmed the above generator documentation was not available at the time of the survey.




 Plan of Correction - To be completed: 03/10/2019

Facility Maintenance Supervisor contacted Palco Sales Corp to perform the annual generator test. Palco will be here on March 8th to perform the generator test. QA will oversee compliance.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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, the facility failed to maintain electrical power cords at two of over fifty rooms.

Findings include:

1. Observation on February 21, 2019, between 10:45 a.m., and 12:45 p.m., revealed the following rooms had misappropriate use of surge protectors:
a. (10:45 a.m.) First floor, Independent Living resident room 109, had a heating pad plugged into a surge protector.
b. (12:45 p.m.) Second floor, business office copier, was plugged into a surge protector.

Interview with the maintenance assistant on February 21, 2019, at 12:45 p.m., confirmed the above surge protector deficiencies.




 Plan of Correction - To be completed: 03/01/2019

1a - Maintenance Supervisor removed the heating pad from the surge protector from Independent living resident room 109 and plugged it directly into the wall receptacle.
1b - Maintenance Supervisor plugged the copier located on the second floor business office directly into the wall receptacle.
QA committee will oversee compliance.

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