Nursing Investigation Results -

Pennsylvania Department of Health
JEWISH HOME OF EASTERN PA
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JEWISH HOME OF EASTERN PA
Inspection Results For:

There are  29 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.
JEWISH HOME OF EASTERN PA - 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 January 22, 2019, at Jewish Home of Eastern PA, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.




 Plan of Correction:


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


Facility ID #360402
Component 01
Main Building 01

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2019, it was determined the Jewish Home of Eastern PA, 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 five story, Type II (000) unprotected, noncombustible building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the following item did not meet the minimum standards for the operation of a facility as set forth by the department and by other state and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Observation on January 22, 2019, at 10:25 a.m., revealed the facility failed to supply the required portable, accurate floor plans identifying smoke barrier walls, fire walls, shafts, hazardous areas, exits, etc. for the Life Safety Survey.

Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the facility did not have accurate floor plans.




 Plan of Correction - To be completed: 03/22/2019

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;

Portable accurate floor plans will be revised to identity smoke barrier walls, fire walls, shafts, hazardous areas, exits, etc. for the Life Safety Survey.
2. How the facility plans to monitor its performance to make sure that solutions are sustained.
Portable accurate floor plans will be reviewed annually in conjunction with the facility's annual emergency response plan.

NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility exceeded the maximum allowable story height for this type of construction, affecting five of five floors within the facility.

Findings include:

1. Observation on January 22, 2019, at 10:00 a.m., revealed the facility exceeded the maximum allowable story height for an unprotected, noncombustible building, by three stories.

Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the facility exceeded the maximum allowable story height for this type of construction.




 Plan of Correction - To be completed: 01/23/2019

K0161 Building Construction Type SS/C

The facility requests to the FSES to be revised under the 2012 Life Safety Code. We submitted a request for a five year time limited waiver for construction type for our building on April 3, 2017.

NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview the means of egress was not free from all obstructions in one instance affecting one of five floors within the facility.

Findings include:

1. Observation on January 22, 2019, at 11:35 a.m., revealed a stationary chair placed in the third-floor, corridor near resident room #321.

Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the egress obstruction.




 Plan of Correction - To be completed: 01/23/2019

K2011 Means of Egress - General
2) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;
The stationary chair was removed near Room 321 on January 22, 2019.

3. How the facility plans to monitor its performance to make sure that solutions are sustained.
The Maintenance Director or designee will conduct random focus audit of Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7. obstructions. Reports will be submitted to the Quality Assurance committee.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain exit stair towers in one instance affecting one of two exit stairs within the facility.

Findings include:

1. Observation on January 22, 2019, at 11:05 a.m., revealed the fourth-floor, stair tower, near resident room #401, had unsealed penetrations around wires.

Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the penetrations.




 Plan of Correction - To be completed: 03/22/2019

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;
The penetration around the wires near the fourth floor stair tower resident room 401 will be sealed using an approved stop gap penetration system.

2. How the facility plans to monitor its performance to make sure that solutions are sustained.
The Maintenance Director or designee will conduct random focus audits of the stair ways and smoke proof enclosures to check for penetrations. Results will be reported to the QA committee in the next quarter.


NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed to maintain the exit discharge one instance affecting one of five floors within the facility.

Findings include:

1. Observation on January 22, 2019, at 1:05 p.m., revealed the exit discharge located outside the Chapel did not lead occupants safely to the public way.

Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the exit discharge.




 Plan of Correction - To be completed: 02/28/2019

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;

Exit signs will be removed from the two chapel doorways leading to the outside. The doors leading to the outside of the building in this 1200 square foot room will be labeled "no exit". This room has two additional doors at separate ends of the room that lead to the exit access corridor.

NFPA 101 STANDARD Vertical Openings - Enclosure: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.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain multiple vertical enclosures, affecting five of five floors within the facility.

Findings include:

1. Observation on January 22, 2019, between 10:00 a.m. and 2:45 p.m., revealed the following:

a. Vertical enclosures protecting heating, cooling and ventilation (HVAC) shafts, adjacent to the exit stair towers, lacked the required two-hour fire resistance rating;

b. The fourth and fifth floor construction, of the Clay Street exit stair tower, consisted of two sheets of drywall on the inside and one sheet of drywall on the corridor and resident room side of metal studs, as well as unprotected steel beams included as part of the enclosure.

Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the vertical enclosures were not protected with the required hourly fire resistance rating.




 Plan of Correction - To be completed: 01/23/2019

The facility requests to use an FSES to be revised under the 2012 Life Safety Code. We submitted a request for a five year time limited waiver for construction type for our building on April 3, 2017.
NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one instance affecting one of five floors within the facility.

Findings include:

1. Observation on January 22, 2019, at 1:45 a.m., revealed the basement level, Generator room, had unsealed penetrations around wires.

Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the penetrations.




 Plan of Correction - To be completed: 03/22/2019

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;
Penetrations around the wires in the basement level near the generator room will be sealed.


2. How the facility plans to monitor its performance to make sure that solutions are sustained.
The Maintenance Director or designee will conduct random focus audits of hazardous areas check for penetrations. Results will be reported to the QA committee in the next quarter.


NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview it was determined the facility failed to maintain records affecting five of five floors within the facility.

Findings include:

1. Documentation review on January 22, 2019, at 10:15 a.m., revealed the facility lacked records for the required annual fire door inspection.

Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the lack of a report.




 Plan of Correction - To be completed: 03/22/2019

1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;

The designee conducting the annual testing of the fire doors will have a signed in-service education sheet to verify training on items inspected. The form used to document the inspections will be revised to in accordance with NFPA 80.



2. How the facility plans to monitor its performance to make sure that solutions are sustained.

Records for the annual fire door inspection and non rated doors will be submitted annually to the Quality Assurance Committee.


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