Pennsylvania Department of Health
HRH TRANSITIONAL CARE UNIT (A D/B/A ENTITY OF HRHS)
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HRH TRANSITIONAL CARE UNIT (A D/B/A ENTITY OF HRHS) - 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 14, 2024, at HRH Transitional Care Unit (a D/b/a Entity Of Hrhs), 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# 083902
Component 01
1998 Link Building

Based on a Medicare/Medicaid Recertification Survey completed on March 14, 2024, it was determined that HRH Transitional Care Unit (a D/b/a Entity Of Hrhs) was not in compliance with the requirements of the Life Safety Code for an existing Nursing 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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.

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain medical gas cylinder storage in one location, affecting one of five levels.

Findings include:

Observation on March 14, 2024, at 12:30 p.m., revealed, on the second floor, bridge building, POD 3 clean utility room, had an unsecured oxygen cylinder.

Interview with the Director of Engineering and Maintenance on March 14, 2024, at 12:30 p.m., confirmed the medical gas cylinder storage deficiency.

Plan of Correction - To be completed: 04/15/2024

The unsecured "E" cylinder was removed and placed in a proper holder in the O2 storage area. Staff will be educated on the proper storage of gas cylinders and documented. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.

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