Nursing Investigation Results -

Pennsylvania Department of Health
HEALTH CENTER AT THE HILL AT WHITEMARSH, THE
Building Inspection Results

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HEALTH CENTER AT THE HILL AT WHITEMARSH, THE
Inspection Results For:

There are  29 surveys for this facility. Please select a date to view the survey results.

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HEALTH CENTER AT THE HILL AT WHITEMARSH, THE - 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 22, 2019, it was determined that The Health Center At The Hill at Whitemarsh 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, it was determined the facility failed to develop
Emergency Plan policies and procedures that addressed subsistence needs for staff and residents, affecting the entire facility.

Findings include

1. Document review on April 22, 2019, at 8:00 am, revealed the facility failed to provide documentation in the emergency preparedness plan that addressed sewage and waste disposal during an emergency.

Interview at the exit conference with the Administrator and Director of Facilities on April 22, 2019, at 2:20 pm, confirmed the documentation was not available.






 Plan of Correction - To be completed: 06/20/2019

The Director of Facilities or designee will update the emergency preparedness plan to address provisions for sewage and waste disposal during an emergency.
The provision will be reviewed each year during the annual plan review for any further updates or revisions.

483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power: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.
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

483.73(e), 485.625(e)
(e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

482.15(e)(1), 483.73(e)(1), 485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), 483.73(e)(2), 485.625(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), 483.73(e)(3), 485.625(e)(3)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at 482.15(h), LTC at 483.73(g), and CAHs 485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.
Observations:
Name: - Component: -- - Tag: 0041

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness Plan to include a plan to ensure the emergency generator provides continuous power during an emergency, affecting the entire facility.

Findings include:

1. Document review on April 22, 2018, at 8:00 am, revealed the facility's Emergency Preparedness plan lacked a written plan and written agreements or contracts with a secondary fuel supplier for the facility's emergency generator in the event the primary fuel supplier is unavailable during an emergency.

Interview at the exit conference with the Administrator and Director of Facilities on April 22, 2019, at 2:20 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 06/20/2019

The Director of Facilities obtained a reliability letter from the facility's secondary fuel provider on the day of survey 4/22/19. This letter has been attached to the existing emergency preparedness plan.
The letter will be reviewed each year during the annual plan review for any further updates or revisions.

Initial comments:Name: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0000


Facility ID# 17900201
Component 01
Long-Term Skilled Unit (Village D)

Based on a Medicare/Medicaid Recertification Survey completed on April 22, 2019 it was determined that The Health Center at the Hill at Whitemarsh 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 three-story, Type II (111), protected non-combustible structure, with a basement, which is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain smoke detectors in a smoke resistive ceiling assembly, affecting 1 of 8 smoke zones within the facility.

Findings include:

1. Observation made on April 22, 2019 at 11:25 am, basement, revealed in the corridor above the smoke barrier doors by the maintenance office, there was a ceiling access panel door that would not latch, creating a gap near a smoke detector.

Interview at the exit conference with the Administrator and Director of Facilities on April 22, 2019, at 2:20 pm, confirmed the gap near a smoke detector.





 Plan of Correction - To be completed: 06/20/2019

The ceiling access panel has been repaired in the basement ceiling corridor to positively latch.
The Facilities Manager or designee will perform monthly rounds to ensure all access panels positively latch in their frames.
Round results will be reported at QAPI for review and further recommendation as indicated.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0353

Based on observation, interview and document review, it was determined the facility failed to ensure that the automatic sprinkler system was inspected; failed to ensure sprinklers were not blocked, affecting the entire facility.

Findings include:

1. Document review on April 22, 2019 at 8:00 am, revealed the facility could not provide documentation a 5 year sprinkler obstruction inspection had been performed.

Interview at the exit conference with the Administrator and Director of Facilities on April 22, 2019, at 2:20 pm, confirmed the documentation was not available.


2. Observation made on April 22, 2019 at 11:15 am, basement, revealed inside the clean linen storage room, items on a shelf were stored approximately 3 inches from a sprinkler.

Interview at the exit conference with the Administrator and Director of Facilities on April 22, 2019, at 2:20 pm, confirmed the sprinkler was obstructed.




 Plan of Correction - To be completed: 06/20/2019

The 5-year sprinkler obstruction inspection shall be completed as specified in the NFPA 25 section 9.7.5-9.7.8 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.
The Facilities Manager or designee will review the inspections for recommendations of repairs to be completed in a timely manner for proper function of the system.
The items inside the clean linen storage room were moved to the proper storage height on the day of survey 4/22/19.
The Facilities Manager or designee will perform monthly rounds to ensure items are not stored within 18" of sprinklers prohibiting proper functionality.
Round Results will be reported at QAPI meetings for review and further recommendation as indicated.

NFPA 101 STANDARD Electrical Systems - Receptacles: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 Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0912

Based on observation and interview, it was determined the facility failed to ensure electrical receptacles were protected and tested, affecting 60 of 60 resident beds within the facility.

Findings include:

1. Document review on April 22, 2019, at 8:00 am, revealed electrical receptacles at resident bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview at the exit conference with the Administrator and Director of Facilities on April 22, 2019, at 2:20 pm, confirmed the receptacles were not tested.


2. Observation made on April 22, 2019 at 1:40 pm, 2nd floor, revealed inside the PT Area, a hydrocollator (wet location) was plugged into a non-GFI type circuit.

Interview at the exit conference with the Administrator and Director of Facilities on April 22, 2019, at 2:20 pm, confirmed a hydrocollator plugged into a non-GFI type circuit.




 Plan of Correction - To be completed: 06/20/2019

All resident room receptacles will be inspected to ensure function and making any necessary repairs upon findings.
The non-GFI type circuit in the PT area was replaced with a proper type circuit for a wet location.
An annual inspection program has been created to ensure proper function of electrical receptacles by a qualified member of the Maintenance Team.
Inspection results will be reported at QAPI for review and further recommendation as indicated.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
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: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure required medical gas signage was posted, affecting 1 of 8 smoke zones within the facility.

Findings include:

1. Observation made on April 22, 2019 at 1:42 pm, 2nd floor, revealed inside the oxygen storage room near room D205, there was no signage identifying full and empty portable oxygen cylinders stored in the room.

Interview at the exit conference with the Administrator and Director of Facilities on April 22, 2019, at 2:20 pm, confirmed there was no signage for the full portable oxygen cylinders being stored in the room.





 Plan of Correction - To be completed: 06/20/2019

Proper signage was replaced in the 2nd Floor oxygen storage room identifying full and empty cylinders on the day of survey 4/22/19.
Purchasing Coordinator or designee will perform weekly rounds to ensure signage is properly placed in oxygen storages rooms.
Round results will be reported at QAPI for review and further recommendation as indicated.


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