Nursing Investigation Results -

Pennsylvania Department of Health
WILLIAM PENN CARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLIAM PENN CARE CENTER
Inspection Results For:

There are  27 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
WILLIAM PENN CARE CENTER - 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 May 13, 2019, it was determined that William Penn Care Center 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) REQUIREMENT Develop EP Plan, Review and Update Annually: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.
[The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.]

* [For hospitals at 482.15 and CAHs at 485.625(a):] The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

The emergency preparedness program must include, but not be limited to, the following elements:]
(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least annually.

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least annually.
Observations:
Name: - Component: -- - Tag: 0004

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to review and update their emergency plan at least annually.

Findings include:

1. Interview and documentation review on May 13, 2019, at 9:00 a.m., revealed the Emergency Preparedness Plan was not updated in over 12 months.

Interview with the Facility Administrator and Maintenance Staff on May 13, 2019, at 1:00 p.m., confirmed the EP plan was not reviewed and updated at least annually.






 Plan of Correction - To be completed: 06/18/2019

In accordance with the regulatory standard for the emergency preparedness manual to be updated and reviewed annually the Administrator and designees immediately reviewed the Emergency preparedness manual. This includes evidence of review by signatures of the medical director, maintenance director, administrator, and director of nursing. The emergency preparedness manual will be brought quarterly to the Quality Assurance and performance improvement committee to ensure compliance.
483.73(c)(1) REQUIREMENT Names and Contact Information: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 [facility] 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:]

(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.

*[For RNHCIs at 403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.

*[For ASCs at 416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For Hospices at 418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.

*[For HHAs at 484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.

*[For OPOs at 486.360(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Name: - Component: -- - Tag: 0030

Based on documentation review and interview, the facility failed to maintain emergency preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:

1. Documentation review on May 13, 2019, at 9:15 a.m., revealed the facility lacked an emergency communication plan that includes names and contact information for the following:
a. Entities providing services under arrangement;
b. Patient physicians;
c. Other facilities;
d. Volunteers.

Interview with the Facility Administrator and Maintenance staff on May 13, 2019, at 1:00 p.m., confirmed the Emergency Preparedness Plan did not include the above items.






 Plan of Correction - To be completed: 06/18/2019

The emergency communication plan was updated to include the names of all entities providing services in the event of an emergency. This includes all of the rounding physicians, surrounding facilities with whom the facility has a memorandum of agreement and volunteers.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 312402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 13, 2019, it was determined that William Penn Care Center 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 non-combustible building, without a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in two instances, affecting the entire facility.

Findings Include:

1. Documentation review on May 13, 2019 between 8:30 a.m. and 8:40 a.m., revealed the facility lacked documentation for the following emergency light testing:
a) The annual 90 minute test of the emergency lights;
b) Nine out of the last twelve months of monthly 30 second testing.

Interview with the Facility Administrator and Maintenance Staff on May 13, 2019, at 1:00 p.m., confirmed the emergency light documentation was not available at the time of the survey.






 Plan of Correction - To be completed: 06/18/2019

An audit log was established by the Maintenance Director to ensure the facility will include the annual 90 minutes test of the emergency lights. All maintenance technicians will attend an in-service on the regulatory standard of annual 90 minutes test of the emergency lights. The Maintenance technicians who perform the monthly 30 second testing will be required to have the signature of the Maintenance Director/Designee to also sign off in acknowledgment that the monthly 30 second testing was completed. This will ensure a double check process to avoid non-compliance.
NFPA 101 STANDARD Fire Alarm System - Installation: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.
Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0341

Based on observation and interview, it was determined the facility failed to install required fire alarm system components in one instance, affecting the entire facility.

Findings include:

1. Observation on May 13, 2019, at 11:30 a.m., revealed there was no smoke detector in the basement, at the main fire alarm control panel.

Interview with the Facility Administrator and Maintenance Staff on May 13, 2019, at 2:30 p.m., confirmed there was not a smoke detector at the main fire alarm panel.






 Plan of Correction - To be completed: 06/18/2019

The facility has contracted a company to install a smoke detector in the basement at the main fire alarm control panel. The work is to be completed by the corrective action date.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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 Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to perform one of two required visual fire alarm system inspections over the last twelve months.

Findings Include:

1. Review of documentation on May 13, 2019, at 8:50 a.m., revealed the facility lacked documentation of a semi-annual visual fire alarm system inspection.

Interview with the Facility Administrator and Maintenance Staff on May 13, 2019, at 1:00 p.m., confirmed the facility lacked documentation of a semi-annual visual inspection of the fire alarm system.






 Plan of Correction - To be completed: 06/18/2019

The facility has contracted a licensed company to perform the regulatory semi-annual visual fire alarm system inspection. The maintenance director/designee will perform a visual check of the fire alarm system on a quarterly basis with findings presented to the quarterly Quality Assurance and Improvement Committee.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to maintain automatic sprinkler system in seven instances, affecting five of ten smoke compartments.

Findings include:

1. Observation on May 13, 2019, revealed the following:

a) 9:46 a.m., m.c. cable being supported by sprinkler pipe above the ceiling, near the elevator on the first floor, above the ceiling;
b) 10:08 a.m., ceiling tile missing, 1st floor, janitor closet in the laundry room;
c) 10:15 a.m., a sprinkler head loaded with lint and dust in the central bath on the second floor;
d) 10:20 a.m., ceiling tile missing and large opening around data cables in the 2nd floor, janitor closet, in wing 324 - 333;
e) 10:36 a.m., a sprinkler head loaded with lint and dust in the 2nd floor laundry, above washer number two;
f) 10:56 a.m., m.c. cable being supported by sprinkler pipe, 2nd floor, above ceiling near the personal care office;
g) 11:03 a.m., m.c. cable being supported by sprinkler pipe, 2nd floor, above ceiling near room 222.

Interview with Facility Administrator and Maintenance Staff on May 13, 2019, at 1:00 p.m.,
confirmed the automatic sprinkler deficiencies.





 Plan of Correction - To be completed: 06/18/2019

The facility has addressed the areas of concern. This includes:

a). The m.c. cable that was supported by the sprinkler pipe above the ceiling near the elevator on the first floor was relocated.
b). The ceiling tile that was missing on the 1st floor, janitor closet in the laundry room was immediately replaced.
c). The sprinkler head that had lint present in the central bath on the second floor was immediately cleaned.
d). The ceiling tile missing and the large opening around the data cables in the second floor, janitor closes on the West wing was replaced and the opening was sealed.
e). The sprinkler head with lint and dust on the second floor laundry above washer number two was immediately cleaned.
f). The m.c. cable that was supported by the sprinkler pipe on the second floor above the ceiling near the personal care office was also relocated.
g). The m.c. cable that was also supported on the second floor sprinkler pipe near room 222 was also relocated.

A whole house audit of the sprinkler pipe was performed to ensure no other cable were supported by the sprinkler pipe.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - 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 ten smoke compartments.

Findings include:

1. Observation on May 13, 2019, at 9:58 a.m., revealed the doors in the first floor smoke wall, between rooms 122 and 123, failed to fully close and latch in the frame when tested.

Interview with the Facility Administrator and the Maintenance Staff on May 13, 2019, at 1:00 p.m., confirmed the smoke barrier doors did not close and latch.







 Plan of Correction - To be completed: 06/18/2019

The facility has contracted a company to assess the doors on the first floor between rooms 122-123. The company will determine if the doors can be fixed. If the doors cannot be repaired then the facility will have them replaced by the corrective action date to ensure the doors fully close and latch the frame when tested.
NFPA 101 STANDARD Electrical Systems - Other: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 Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined that the facility failed to maintain electrical wiring in one instance affecting one of ten smoke compartments. Installation shale be in compliance with NFPA 70, National Electrical Code. 19.5.1.1, NFPA 101.

Findings include:

1. Observation on May 13, 2019, at 10:45 a.m., revealed an open electrical junction box above the transfer switch in the second floor mechanical room.

Interview with the Facility Administrator and the Maintenance Staff on May 13, 2019, at 1:00 p.m., confirmed the open electrical junction box.






 Plan of Correction - To be completed: 06/18/2019

The facility immediately addressed the open electrical junction box above the transfer switch in the second floor mechanical room. The Maintenance Director performed a visual inspection of the entire room to ensure no other junction boxes were open and/or had a plate present to properly ensure closure.
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, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of ten smoke compartments.

Findings include:

1. Observation on May 13, 2019, at 10:37 a.m., revealed a microwave was plugged into a surge protector in the second floor Dietary office.

Interview with the Facility Administrator and Maintenance Staff on May 13, 2019, at 1:00 p.m., confirmed the misuse of electrical wiring.






 Plan of Correction - To be completed: 06/18/2019

The Maintenance staff immediately unplugged the surge protector that was observed with a microwave plugged into it on the second floor dietary office. The Maintenance staff conducted a visual audit of the entire building to ensure no other violations of this kind were present. These audits will continue and presented to the Administrator on a weekly basis for six weeks.

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