Nursing Investigation Results -

Pennsylvania Department of Health
HEALTH CARE CENTER AT WHITE HORSE VILLAGE, THE
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HEALTH CARE CENTER AT WHITE HORSE VILLAGE, THE
Inspection Results For:

There are  41 surveys for this facility. Please select a date to view the survey results.

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HEALTH CARE CENTER AT WHITE HORSE VILLAGE, THE - 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 March 26, 2018, it was determined that The Health Care Center At White Horse Village had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.









 Plan of Correction:


483.73(a)(1)-(2) REQUIREMENT Plan Based on All Hazards Risk Assessment: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.
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

*[For LTC facilities at 483.73(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

*[For ICF/IIDs at 483.475(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at 418.113(a)(2):] (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.
Observations:
Name: - Component: -- - Tag: 0006

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

Findings include:

1. Document review on March 26, 2018, beween 8:30 am 10:30 am, revealed the facility failed to provide an emergency preparedness plan that identified a facility based table top risk assessment had been conducted.

Interview with the Administrator and Maintenance Director at the exit conference on March 26, 2018, at 2:30 pm, confirmed the emergency preparedness plan did not include the above point.

*****************

Observation made during an on-site Revisit conducted on May 05, 2018, between 9:00 am and 10:00 am, revealed the following:

Item 1- Not Completed. The facility did not conduct the table top risk assesment as part of the Emergency Preparedness Program.

Interview with the Maintenance Director at the exit conference on May 14, 2018, at 9:50 am, confirmed the table top risk assessment was not conducted.













 Plan of Correction - To be completed: 05/21/2018

In regard to F483.73 a facility based table top risk assessment has been scheduled and completed on 5/17/2018.
Facility audit completed to ensure all components met regarding all hazards approach.
A representative, Mark Ross, from the Hospital Association of Pennsylvania (HAP)was present to facilitate the drill.

Staff educated on requirement of table top drill as per regulatory compliance

NHA and Director of Property and facility will monitor compliance throughout the year through audits, and findings will be brought to QAPI committee.

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


Facility ID# 235902
Building 01
Health Care Center

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on March 26, 2018, it was determined that The Health Care Center at White Horse 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 two-story, Type II (111), protected noncombustible structure, with a basement, which is fully sprinklered.













 Plan of Correction:



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