Nursing Investigation Results -

Pennsylvania Department of Health
PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILLS, LLC
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILLS, LLC
Inspection Results For:

There are  3 surveys for this facility. Please select a date to view the survey results.

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PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILLS, LLC - 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 7, 2019, it was determined that Paramount Nursing and Rehabilitation At South Hills, LLC had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(d)(2) REQUIREMENT EP Testing Requirements: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.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

*[For LTC Facilities at 483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For RNHCIs at 403.748 and OPOs at 486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039
Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to maintain documentation of exercises to test the emergency plan.

Findings include:

1. Interview and documentation review on February 7, 2019, at 9:35 a.m., revealed the facility lacked documentation of exercises conducted to test the emergency plan at least annually.

Interview with the Facility Administrator and Maintenance Director on February 7, 2019, at 9:35 a.m., confirmed the documentation of exercises was not maintained.


 Plan of Correction - To be completed: 03/04/2019

A full scale community based emergency fire drill was conducted on Feb 19,20019 at 2:30 pm. Facility census was 15 and all 15 residents were evacuated to the community next door. All emergency resident information and e-mars were transported and evacuated with the residents. A head count revealed the evacuation was complete in 5 minutes. Mr. Tom Bonura, Fire Instructor/Inspector was present to supervise the disaster drill. All staff were in-serviced by the DON and Maintenance Manager on disaster Training on Feb 19-20, 2019. Disaster codes were placed on the back of all staff name tags and disaster codes were posted in the nurses station, the physical therapy gym, Maintenance , Dietary and Housekeeping offices and employee lounge. To ensure the deficiency does not reoccur a full scale tornado disaster has been planned for August of 2019. This will be coordinated with the local EMS Department. Disaster Training Education will be provided to all new employees at the time of hire and before unsupervised job duties. This will be conducted for all employees upon hire and annually by the Executive Director and the Maintenance Manager. The education will be part of the employee personnel record. The Business Office Manager or designee will audit employee personnel records monthly x4 for compliance. Disaster drills and Disaster Education will be reported to the QAPI Committee for the next 3 quarters. Any non-compliance issues will be reviewed and corrected.
Initial comments:Name: PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILL - Component: 01 - Tag: 0000


Facility ID# 24670201
Component 01
Skilled Nursing Unit

Based on a Medicare/Medicaid Recertification Survey completed on February 7, 2019, it was determined that Paramount Nursing and Rehabilitation at South Hills, LLC was not in compliance with the following requirements of the Life Safety Code for a new 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 III (211), protected ordinary building, without a basement, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILL - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating to separate the health care occupancy from other occupancies, in one of one occupancy separations.

Findings include:

1. Observation on February 7, 2019, at 10:36 a.m., revealed an excessive gap between the meeting edges of the fire doors, that would not meet the requirement for a 2-hour fire resistance rating.

Interview with the Facility Administrator and Maintenance Director on February 7, 2019, at 10:36 a.m., confirmed the fire doors in the 2 hour occupancy separation barrier had an excessive gap.



 Plan of Correction - To be completed: 03/04/2019

Facility received a quote from Builders Hardware/The Door Company and have authorized to repair the excessive gaps in the 2 hour occupancy fire doors. Builders Hardware/The Door Company is scheduled to repair the excessive gaps on Thursday, February 28, 2019.
NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILL - Component: 01 - Tag: 0291
Based on documentation review and interview, it was determined the facility failed to maintain emergency task lighting, affecting the entire facility.

Findings include:

1. Review of documentation on February 7, 2019, at 9:40 a.m., revealed the facility lacked documentation for monthly and annual testing of the battery backup lighting located in the emergency generator automatic transfer switch room.

Interview with the Facility Administrator and Maintenance Director on February 7, 2019, at 9:40 a.m., confirmed the facility lacked testing documentation for emergency backup lighting, at the time of the survey.


 Plan of Correction - To be completed: 03/04/2019

The battery back up lighting system was tested for 90 minutes on 2/20/19 by the Maintenance Manager and documentation was maintained. The Maintenance Manager was in-serviced by the Vice President of Facilities Management on the regulation for testing the emergency lighting monthly for 30 seconds and annually for 90 minutes. The batteries in the device will be replaced annually or more frequently as needed. The Executive Director will audit generator emergency lighting documentation of testing for 3 months and annually for 1 month for compliance with the regulation. Emergency lighting will be reviewed by QAPI quarterly x 4 for continued compliance. Any non-compliance issues will be corrected.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 NEW
Doors in smoke barriers have at least a 20 minute fire protection rating or are at least 1-3/4 inch thick solid bonded core wood.
Required clear widths are provided per 18.3.7.6(4) and (5).
Nonrated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal-sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction.
Doors shall be self-closing and rabbets, bevels, or astragals are required at the meeting edges. Positive latching is not required.
18.3.7.6, 18.3.7.7, 18.3.7.8
Observations:
Name: PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILL - Component: 01 - Tag: 0374
Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of two smoke compartments.

Findings include:

1. Observation on February 7, 2019, at 10:52 a.m., revealed the doors in the smoke barrier, near room 1005, lacked rabbets, bevels, or astragal and had an excessive gap between the meeting edges of the doors.

Interview with the Facility Administrator and Maintenance Director on February 7, 2019, at 10:52 a.m., confirmed the smoke barrier doors had an excessive gap.


 Plan of Correction - To be completed: 03/04/2019

Facility received a quote from Builders Hardware/The Door Company and have authorized to repair the excessive gaps in the 2 hour occupancy fire doors. Builders Hardware/The Door Company is scheduled to repair the excessive gaps on Thursday, February 28, 2019.
NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7
Observations:
Name: PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILL - Component: 01 - Tag: 0712
Based on documentation review and interview, it was determined the facility failed to perform 10 of 12 required fire drills.

Findings include:

1. Review of documentation on February 7, 2019, at 9:15 a.m., revealed the facility lacked required documentation for the following fire drills, at the time of the survey:

a) Second shift in the first quarter of the year;
b) First shift in the second quarter of the year;
c) Second shift in the second quarter of the year;
d) Third shift in the second quarter of the year;
e) First shift in the third quarter of the year;
f) Second shift in the third quarter of the year;
g) Third shift in the third quarter of the year;
h) First shift in the fourth quarter of the year;
i) Second shift in the fourth quarter of the year;
j) Third shift in the fourth quarter of the year.

Interview with the Facility Administrator and Maintenance Director on February 7, 2019, at 9:15 a.m., confirmed the facility lacked fire drill records and sign-in sheets for the ten undocumented fire drills.



 Plan of Correction - To be completed: 03/04/2019

Maintenance Director has been educated on both the facility policy "Fire Drill Procedure" and the requirements of 209.8. Fire drills. Maintenance Director will bring results of the monthly fire drills to monthly QAPI meetings for review. Administrator or designee will review fire drill documentation monthly for 6 months as part of the QAPI meeting to ensure compliance. Any concerns will be corrected and reviewed with the Maintenance Director by the Administrator or designee. The QAPI Committee will determine the need for continuous monitoring.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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: PARAMOUNT NURSING AND REHABILITATION AT SOUTH HILL - Component: 01 - Tag: 0918
Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

1. Review of documentation on February 7, 2019, at 9:32 a.m., revealed the facility lacked documentation for annual maintenance and testing, and a load bank test for the emergency generator.


Interview with the Facility Administrator and Maintenance Director on February 7, 2019, at 9:32 a.m., confirmed the facility lacked annual generator testing documentation, at the time of the survey.



 Plan of Correction - To be completed: 03/04/2019

Annual maintenance and testing, and a load bank test for the emergency generator will be completed on February 26, 2019. The generator maintenance testing and load bank test will be completed annually per regulation. Documentation of the testing will be maintained by the Maintenance Manager. The Maintenance Manager was educated by the Vice President of Facilities Management on the regulation for annual maintenance, testing and load bank testing of the emergency generator. The Executive director or designee will audit the generator records for compliance with annual testing. Generator records will be reviewed at QAPI for the next year for compliance. Any non-compliance issues will be reviewed and corrected.

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