Nursing Investigation Results -

Pennsylvania Department of Health
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  35 surveys for this facility. Please select a date to view the survey results.

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VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0000

Facility ID# 480202
Component 01
Main Building

Based on an Abbreviated survey, as part of a complaint investigation completed on February 8, 2019, it was determined that Valley Manor Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one story, Type V (000), unprotected wood frame construction, with a basement, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Sprinkler 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.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0351







Based on documentation review, observation and interview, it was determined the facility failed to install, submit plans, obtain required layout approvals, perform acceptance testing, and obtain an inspection and approval from the authority having jurisdiction after the completion of the water supply installation in accordance with NFPA 13 and NFPA 22, affecting the entire facility.

Findings include:

1. Review of documentation, observation and interview with Administration and Maintenance on February 8, 2019, between 1:00 PM and 1:40 PM revealed the water supply for the building automatic sprinkler system was changed from municipal water to two large storage containers. The system was not installed in accordance with NFPA 13 and NFPA 22.

a) The facility failed to notify the authority having jurisdiction (Department of Health) of the water supply change and obtain approval for the new water containers and piping system.

b) The facility failed to submit plans to the Department of Health for the water containers.

c) The facility failed to provide complete information regarding the tank piping on the tank side of the connection to the sprinkler system to the Department of Health for approval.

d) The facility failed to perform and provide acceptance testing to the Department of Health.

e) The facility failed to obtain an inspection and approval of the new water supply, by the Department of Health prior to placing the system in service.

Interview with the Administrator and Maintenance Director on February 8, 2019, at 1:40 PM confirmed the facility failed to install, submit plans, obtain required layout approvals, perform acceptance testing, and obtain an inspection and approval from the authority having jurisdiction after the completion of the water supply installation in accordance with NFPA 13 and NFPA 22


 Plan of Correction - To be completed: 04/02/2019

The facility will be submitting a request for a time limited waiver to obtain approval for the current fire pump.
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: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0353

Based on documentation review, observation and interview, it was determined the facility failed to inspect, test and maintain the sprinkler system water supply in accordance with NFPA 25, affecting the entire facility.

Findings include:

1. Observation and interview with Administration and Maintenance on February 8, 2019, between 1:00 PM and 1:40 PM revealed that the water storage containers, supplying water to the building sprinkler system, lacked the required testing, maintenance and inspections required by NFPA 25, Section 9.

Interview with the Administrator and Maintenance Director on February 8, 2019, at 1:40 PM confirmed the sprinkler system water supply was not tested, inspected and maintained in accordance with NFPA 25.

2. Review of documentation, observation and interview with Administration and Maintenance on February 8, 2019, between 1:00 PM and 1:40 PM revealed that the fire pump, for the building automatic sprinkler system, was not operational at the time of the survey. The facility installed the fire pump and fire pump housing without approved plans or inspection by the department of health.

Interview with the Administrator and Maintenance Director on February 8, 2019, at 1:40 PM confirmed the sprinkler system water supply was not tested, inspected and maintained in accordance with NFPA 25.



 Plan of Correction - To be completed: 04/09/2019

Facility will conduct weekly inspection of water level and visual inspection of piping from water tanks to the fire pump.
Fire pump does perform a weekly test to ensure water flow.

The facility went on Fire Watch during the time that the fire pump was repaired.

The facility will maintain fire watch until the plans have been submitted, approved, and final inspection by Harrisburg Plan Review.

The facility is submitting a time limited waiver for the approval of the fire pump and to replace the temporary water tanks with permanent water supply.

Corrective Action Date: April 9, 2019


NFPA 101 STANDARD Sprinkler System - Out of Service: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 - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)
Observations:
Name: MAIN BUILDING 01 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0354
Based on documentation review and interview, it was determined the facility failed to perform an approved fire watch throughout the building when the sprinkler system was out of service for more than 10 hours in a 24-hour period.

Findings include:

1. Review of documentation on February 8, 2019, at 1:40 PM revealed the facility did not perform fire watches throughout the building as required when the sprinkler system was out of service for more than 10 hours in a 24 hour period. The facility could only provide partial documentation after February 2, 2019, and lacked any documentation of fire watches after February 4, 2019. The sprinkler system is still not fully operational.

Interview with the Administrator and Maintenance Director on February 8, 2019, at 1:40 PM confirmed that only partial fire watches were completed after February 2, 2019, and no documentation of fire watches was completed after February 4, 2019.


 Plan of Correction - To be completed: 04/02/2019

The facility is maintaining fire watches and will send documentation to the Norristown field office for review. Fire watches will continue until plans have been submitted to DOH Plan review for the sprinkler system, to include the water supply and fire pump; Plans are approved and an occupancy inspection has been performed and approved by the Norristown Field Office.

Staff has been educated on performing fire watches.

The fire pump has been inspected and is providing protection to the facility. .

Corrective Action 4/2/2019

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