Nursing Investigation Results -

Pennsylvania Department of Health
PINE RUN HEALTH CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PINE RUN HEALTH CENTER
Inspection Results For:

There are  41 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.
PINE RUN HEALTH 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 January 9, 2019, it was determined that Pine Run Health Center was not in compliance with the requirements of 42 CFR 483.73.



 Plan of Correction:


483.73(b)(1) REQUIREMENT Subsistence Needs for Staff and Patients: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.
[(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at 418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Name: - Component: -- - Tag: 0015
Based on document review and interview, it was determined the facility failed to develop
Emergency Plan policies and procedures that addressed subsistence needs for staff and residents, affecting the entire facility.

Findings include

1. Document review on January 9, 2019, at 8:00 am, revealed the facility failed to provide documentation in the emergency preparedness plan that addressed subsistence needs for staff and residents during an emergency as follows:

a. Food, water, medical and pharmaceutical supplies
b. Alternate sources of energy to maintain the following:
i. Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
ii. Emergency lighting.
iii. Fire detection, extinguishing, and alarm systems.
iv. Sewage and waste disposal.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 01/21/2019

The policy referred to in tag 0015 was in place at PRHC, however not available for review at time of inspection. The policy was copied from PRHC's emergency disaster manual and placed in a newly created Master Emergency Preparedness manual on 1/21/2019. The Master EP manual will be located in the safety/security office and updated as necessary.
The EP manual will be reviewed annually by the QAPI committee.
483.73(b)(2) REQUIREMENT Procedures for Tracking of Staff and Patients: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.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.] At a minimum, the policies and procedures must address the following:]

(2) A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

*[For PRTFs at 441.184(b), LTC at 483.73(b), ICF/IIDs at 483.475(b), PACE at 460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.

*[For Inpatient Hospice at 418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.

*[For CMHCs at 485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For OPOs at 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

*[For ESRD at 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0018
Based on documentation review and interview, it was determined the facility failed to develop
Emergency Plan policies and procedures that included a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location if on-duty staff and sheltered patients are relocated during an emergency, affecting the entire facility.

Findings include:

Document review on January 9, 2019, at 8:00 am, revealed the Facility's Emergency Preparedness Plan did not include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location if on-duty staff and sheltered patients are relocated during an emergency.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/08/2019

The PRHC Operational Disaster Plan section 1 will be updated to include a system to track the locations of on duty staff and the sheltered patient's in place during the emergency.
The updated plan will be placed in the Master Emergency Preparedness Manual; the manual will be maintained in the safety/ security office and updated as necessary.
The EP manual will be reviewed annually by the QAPI committee.


483.73(b)(3) REQUIREMENT Policies for Evac. and Primary/Alt. Comm.: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.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For RNHCs at 403.748(b)(3) and ASCs at 416.54(b)(2):]
Safe evacuation from the [RNHCI or ASC] which includes the following:
(i) Consideration of care needs of evacuees.
(ii) Staff responsibilities.
(iii) Transportation.
(iv) Identification of evacuation location(s).
(v) Primary and alternate means of communication with external sources of assistance.

* [For CORFs at 485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at 485.727(b)(1), and ESRD Facilities at 494.62(b)(2):]
Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients.

* [For RHCs/FQHCs at 491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0020
Based on document review and interview, it was determined the facility failed to ensure the emergency preparedness plan included documentation that addressed safe evacuation from the facility, which included consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance, affecting the entire facility.
Findings include:
1. Document review on January 9, 2019, at 8:00 am, revealed there was no documentation available in the emergency preparedness plan that addressed safe evacuation from the facility, which included consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance, affecting the entire facility.
Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 01/24/2019

PRHC's previously established Operational Disaster Plan for tag 0020 addressing the safe evacuation and care and treatment of the evacuees, staff responsibilities, transportation, and a primary and alternate means of communication with internal and external sources was in place however not available for review at time of inspection. It was copied and placed in the Master Emergency Preparedness Manual, as of 01/24/2019.
The EP manual will be maintained in the safety/security office and updated as needed.
The EP manual will be reviewed annually by the QAPI committee.
483.73(b)(5) REQUIREMENT Policies/Procedures for Medical Documentation: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.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(5) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at 403.748(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Name: - Component: -- - Tag: 0023
Based on document review and interview, it was determined the facility failed to develop and maintain an Emergency Preparedness plan that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, affecting the entire facility.
Findings include:
1. Document review on January 9, 2019, at 8:00 am, revealed the facility did not have an Emergency Plan that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/08/2019

PRHC will be updating the Information Technology Policy and procedure to include an up to date procedure that will be a part of the Emergency preparedness manual. The policy will include a system that preserves patient information as well as secures and maintains availability of records.
The Policy will be placed in the Master EP manual, it will be maintained by the safety/security office and updated as needed.
The EP manual will be reviewed annually by the QAPI committee.
483.73(b)(6) REQUIREMENT Policies/Procedures-Volunteers and Staffing: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.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

*[For RNHCIs at 403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.

*[For Hospice at 418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Name: - Component: -- - Tag: 0024
Based on document review and interview, it was determined the facility failed to ensure policies and procedures were in place addressing the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, affecting the entire facility.

Findings include:

1. Document review on January 9, 2019, at 8:00 am, revealed the Facilities Emergency Preparedness Plan did not have policy and procedures addressing the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/08/2019

PRHC's established Operational Disaster Plan will be updated to include PRHC's Emergency Chain of Command phone listing to be followed in the event of an emergency, and provisions to address a surge of staffing needs. The existing plan for integrating the role of state and federal assistance will be updated if necessary.
The plan will be placed in the Master EP manual which will be maintained in the safety/security office and updated as necessary.
The EP manual will be reviewed annually by the QAPI committee.
483.73(b)(7) REQUIREMENT Arrangement with Other Facilities: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.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

*[For Hospices at 418.113(b), PRFTs at 441.184,(b) Hospitals at 482.15(b), and LTC Facilities at 483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

*[For PACE at 460.84(b), ICF/IIDs at 483.475(b), CAHs at 486.625(b), CMHCs at 485.920(b) and ESRD Facilities at 494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

*[For RNHCIs at 403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients.
Observations:
Name: - Component: -- - Tag: 0025

Based on document review and interview, it was determined the facility failed to develop and maintain an Emergency Preparedness plan that included the development of arrangements with other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients, affecting the entire facility

Findings include:

1. Document review on January 9, 2019, at 8:00 am, revealed the Facilities Emergency Preparedness Plan did not include the development of arrangements with other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 01/24/2019

PRHC's previously established transfer agreements, were in place however not available for review at the time of the inspection; have been copied and placed in the Master EP manual, as of 01/24/2019.
The Master EP manual will be maintained in the safety/security office and updated as necessary.
The Master EP manual will be reviewed annually by the QAPI committee.
483.73(b)(8) REQUIREMENT Roles Under a Waiver Declared by Secretary: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.
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at 403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.
Observations:
Name: - Component: -- - Tag: 0026
Based on document review and interview, it was determined the facility failed to develop Policies and Procedures to include the facility's role in providing alternate care at alternate care sites during emergencies, as part of their Emergency Preparedness plan, affecting the entire facility.

Findings Include:

1. Document review on January 9, 2019, at 8:00 am, revealed the Emergency Preparedness plan did not include Policies and Procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver during a declared emergency.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/08/2019

PRHC will have a policy in place to be compliant with section 1135 of the ACT in the provision of care and treatment at an alternate care site identified by emergency management officials.
The Policy will be placed in the Master Emergency Preparedness Manual. The EP manual will be maintained in the safety/security office and updated as necessary.
The EP manual will be reviewed annually by the QAPI committee.
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 document review and interview, it was determined the facility's emergency preparedness communication plan failed to include the required names and contact information, affecting the entire facility.

Findings Include:

1. Document review on January 9, 2019, at 8:00 am, revealed the facility's emergency preparedness communication plan did not include the names and contact information for the following:

(i) Residents physicians.
(ii) Other Facilities

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 01/24/2019

PRHC has placed the required names and contact information in the Master Emergency Preparedness Manual as of 1/24/2019.
The Mater EP manual will be maintained in the safety/security office and updated as necessary.
The Master EP manual will be reviewed annually by the QAPI committee.
483.73(c)(2) REQUIREMENT Emergency Officials 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:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

*[For LTC Facilities at 483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, or local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.

*[For ICF/IIDs at 483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.
Observations:
Name: - Component: -- - Tag: 0031
Based on documentation review and interview, it was determined the facility failed to develop
an Emergency Preparedness Communication Plan that contained all the required contact information, affecting the entire facility.

Findings include

Document review on January 9, 2019 at 8:00 am, revealed the facility's Emergency Preparedness Communication Plan did not contain the contact information for the Office of the State Long-Term Care Ombudsman.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 03/08/2019

PRHC has added the the required state and local authority numbers, to the Master Emergency Preparedness manual.
The Mater EP manual will be maintained in the safety/security office and updated as necessary.
The Master EP manual will be reviewed annually by the QAPI committee.

483.73(c)(3) REQUIREMENT Primary/Alternate Means for Communication: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:

(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.

*[For ICF/IIDs at 483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Name: - Component: -- - Tag: 0032
Based on documentation review and interview, it was determined the facility failed to develop
an Emergency Preparedness Communication Plan that contained all the required contact information, affecting the entire facility.

Findings include

Document review on January 9, 2019 at 8:00 am, revealed the facility failed to develop
an Emergency Preparedness Communication Plan that contained a primary and alternate means for communicating with the following:

(i) Facility staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 01/21/2019

The previous established Operational Disaster Plan which addresses tag 0032 for a primary and alternate means of communication was in place however not available for review at the time of inspection was copied and placed in the Master Emergency Preparedness manual on 1/21/2019.
The master EP manual will be maintained in the safety/ security office and updated as necessary.
The EP manual will be reviewed annually by the QAPI committee.

483.73(c)(4)-(6) REQUIREMENT Methods for Sharing 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:

(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.

(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under 484.102(c), CORFs under 485.68(c), and RHCs/FQHCs under 491.12(c).]

(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).

*[For RNHCIs at 403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.

*[For RHCs/FQHCs at 491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).
Observations:
Name: - Component: -- - Tag: 0033
Based on document review and interview, it was determined the facility's emergency preparedness communication plan failed to include a method for sharing information and medical documentation for patients under the facility's care, with other health care providers to maintain the continuity of care, affecting the entire facility

Findings include:

1. Document review on January 9, 2019 , at 8:00 am, revealed the facility's emergency preparedness communication plan lacked a method for sharing information and medical documentation for patients under the facility's care, with other health care providers to maintain the continuity of care.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/08/2019

PRHC's admissions policy and procedure for sharing health information in a HIPAA compliant manner, will be added to the Master Emergency preparedness manual. The policy includes patient signature to share information as necessary in the event of an emergency.
The Master emergency preparedness manual will be maintained in the safety/security office and updated as necessary.
The master EP manual will be reviewed annually by the QAPI committee.
483.73(c)(7) REQUIREMENT Information on Occupancy/Needs: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:

(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

*[For Inpatient Hospice at 418.113:] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Name: - Component: -- - Tag: 0034
Based on document review and interview, it was determined the facility's emergency preparedness communication plan did not include a means of providing information about the facility's needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee, affecting the entire facility.

Findings include:

1. Document review on January 9, 2019, at 8:00 am, revealed the facility's emergency preparedness communication plan did not include a means of providing information about the Facillity's needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/08/2019

PRHC will develop a policy and procedure for emergency preparedness that includes means of communication about the facilities needs and its ability to provide assistance to the authority having jurisdiction, the incident command center, or designee.
The staff will be educated on the policy and it will be placed in the Master Emergency preparedness manual.
The EP manual will be reviewed annually by the QAPI committee.
483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with Patients: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 [LTC facility and ICF/IID] 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:

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.
Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives, affecting the entire facility.

Findings include:

1. Document review on January 9, 2019, at 8:00 am, revealed the facility lacked a written Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives.
Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 03/08/2019

PRHC will develop a policy and procedure to include sharing facility emergency preparedness plans and polices with family members, and resident representatives.
The appropriate staff will be educated and the policy will be placed in the Master Emergency preparedness manual.
The Master EP manual will be maintained in the safety/security office and updated as necessary.
The Master EP manual will be reviewed annually by the QAPI committee.
483.73(d) REQUIREMENT EP Training 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.
(d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at 483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. The ICF/IID must meet the requirements for evacuation drills and training at 483.470(h).

*[For ESRD Facilities at 494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be reviewed and updated at least annually.
Observations:
Name: - Component: -- - Tag: 0036

Based on documentation review and interview, it was determined the facility failed to develop
an emergency preparedness training program that is based on the facility's emergency preparedness plan, affecting the entire facility.

Findings include:

Document review on January 9, 2019 at 8:00 am, revealed the facility failed to develop an emergency preparedness training program.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.






 Plan of Correction - To be completed: 03/08/2019

PRHC's educational policy and procedure for education of staff upon hire and annual training has been added to the Master Emergency Preparedness manual. A schedule outlining the annual education regarding the EP process is included.
The master EP manual will be maintained in the safety/security office and updated as necessary.
The master EP manual will be reviewed annually by the QAPI committee.

483.73(d)(1) REQUIREMENT EP Training Program: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.
(1) Training program. The [facility, except CAHs, ASCs, PACE organizations, PRTFs, Hospices, and dialysis facilities] must do all of the following:

(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For Hospitals at 482.15(d) and RHCs/FQHCs at 491.12:] (1) Training program. The [Hospital or RHC/FQHC] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For Hospices at 418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least annually.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.

*[For PRTFs at 441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.

*[For PACE at 460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.

*[For CORFs at 485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.

*[For CAHs at 485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

*[For CMHCs at 485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least annually.

Observations:
Name: - Component: -- - Tag: 0037

Based on documentation review and interview, it was determined the facility failed to maintain a training program that is based on the facility's emergency preparedness plan, affecting the entire facility.

Findings include:

Review of documentation on January 9, 2019 at 8:00 am, revealed the facility failed to perform training to the emergency preparedness plan that included the following:

a. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
b. Provide emergency preparedness training at least annually.
c. Maintain documentation of the training.
d. Demonstrate staff knowledge of emergency procedures.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the training program documentation was not available.





 Plan of Correction - To be completed: 03/08/2019

PRHC's policy and procedure on education of new and existing staff has been placed in the master emergency preparedness manual. An outline and schedule of the EP plan is included, the staff have been trained at time of hire, and annually. Staff completion records will be included in the manual as well as volunteers and any contracted employees.
The master EP manual will be maintained in the safety/security office and will be updated as necessary.
The master EP manual will be reviewed annually by the QAPI committee.
483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power: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.
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

483.73(e), 485.625(e)
(e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

482.15(e)(1), 483.73(e)(1), 485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), 483.73(e)(2), 485.625(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), 483.73(e)(3), 485.625(e)(3)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at 482.15(h), LTC at 483.73(g), and CAHs 485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.
Observations:
Name: - Component: -- - Tag: 0041
Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan to include a plan to ensure the emergency generator provides continuous power during an emergency, affecting the entire facility.

Findings include:

1. Document review on January 9, 2019, at 8:00 am, revealed the facility ' s Emergency Preparedness plan lacked a written plan and written agreements or contracts with a secondary fuel supplier for the facility's emergency generator in the event the primary fuel supplier is unavailable during an emergency.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not available.



 Plan of Correction - To be completed: 03/08/2019

PRHC's Operational Disaster Plan section 6: "loss of power" will be updated to include the names and contact information of the 2 contactors engaged to provide fuel for the generators of PRHC. ( 1 primary and 1 secondary)
The updated plan will be placed in the master EP manual.
The master EP manual will be maintained in the safety/security office and updated as necessary.
The EP manual will be reviewed annually by the QAPI committee.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID # 680502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 9, 2019, it was determined that Pine Run Health 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 five-story, Type II (222), fire resistive construction, which is fully sprinklered.



 Plan of Correction:


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 observations and interview, it was determined the facility failed to ensure that stair tower enclosures were free of items not serving the stair tower, affecting one of three stair tower enclosures within the facility.

Findings Include:

1. Observations made on January 9, 2019, between 10:15 am and 1:45 pm, revealed inside stair tower enclosure # 2 the following items were mounted on the stair tower wall in the following locations:

a. 10:15 am, wet floor sign enclosures were mounted to the stair tower wall on all five levels.
b. 1:45 pm, cable wires were running along the stair tower at the 2nd floor landing.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019, at 2:50 pm, confirmed the items mounted within the stair tower enclosure, in the above named locations.










 Plan of Correction - To be completed: 03/08/2019

The mounted wet floor signs from stair tower #2 have been removed and the walls repaired with concrete.
The cable wires were removed and the walls repaired with concrete.
The appropriate staff will be educated on the tag 0225 to ensure the stair tower remains free of any articles that do not serve the stair tower.
Bi annual audits of the stair tower will be completed and the results shared with the QAPI committee.

NFPA 101 STANDARD Vertical Openings - 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.
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 the fire resistive rating of elevator shaft enclosures, affecting 2 of 5 levels within the facility.

Findings include:

1. Observations made on January 9, 2019, between 12:55 pm and 1:55 pm, revealed an unknown yellow spray foam material was used to seal gaps between the elevator shaft wall and the corrugated metal deck in the following locations:

a. 12:55 pm, in the corridor, above the doors to the 3rd floor service elevator, above the suspended ceiling.
b. 1:55 pm, in the corridor, above the doors to the 2nd floor service elevator, above the suspended ceiling.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed an unknown yellow spray foam material was used to seal the gaps, in the above named locations.




 Plan of Correction - To be completed: 01/11/2019

The spray foam was removed from the following area's:
1) the corridor above the doors to the 3rd floor service elevator above the suspended ceiling
2) the corridor above the doors to the 2nd floor service elevator.
The penetrations were sealed with an approved through- penetration fire-stop system;using 3m CP25WB fire caulk on 1/11/2019.
Maintenance Director or designee will complete quarterly audits to ensure no gaps occur and report to the QAPI committee.
NFPA 101 STANDARD Smoke Detection: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.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain smoke detectors in a smoke resistive assembly, affecting 1 of 9 smoke zones within the facility.

Findings include:

Observation made on January 9, 2019, at 2:12 pm, revealed in the 1st floor corridor near the center stair tower door, there was a hole in a suspended ceiling tile near a smoke detector.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the hole in a suspended ceiling tile near a smoke detector.





 Plan of Correction - To be completed: 03/08/2019

The ceiling tile located in the 1st floor corridor center stair tower has been replaced.
The maintenance director or designee will perform quarterly rounds and inspect for any damaged tiles and replace as necessary.
The audits will be submitted and reviewed by the QAPI committee.
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 - Component: 01 - Tag: 0353

Based on document review, observation and interview it was determined the facility failed to ensure that automatic sprinkler system components were maintained and inspected, affecting the entire facility.

Findings include:

1. Document review January 9, 2019, at 8:50 am, revealed that the facility did not perform a 1st quarter 2018 sprinkler inspection.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the documentation was not availible at time of survey.

2. Document review January 9, 2019, at 9:00 am, revealed that the facility did not perform a the required 5-year Obstruction Inspection.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the required documentation was not availible at time of survey.

3. Observation made on January 9, 2019, at 11:05 am, 4th floor, revealed a sprinkler with debris on it inside resident room # 416.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the sprinkler with debris on it.

4. Observations made on January 9, 2019, between 1:35 pm and 2:10 pm, revealed ceiling mounted sprinklers missing escutcheons in the following locations:

a. 1:35 pm, within the 2nd floor nurses station area.
b. 2:10 pm, inside the 1st floor central supply storage room.
c. 2:20 pm, 1st floor kitchen.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the sprinklers with missing escutcheons in the above named locations.





 Plan of Correction - To be completed: 03/08/2019

1) The sprinkler inspections are performed by an outside contractor. PRHC will maintain an accurate schedule of inspection and maintain records accordingly.
Inspections for 2019 have been scheduled and will be audited quarterly and maintained by the maintenance director or designee.
2) PRHC has contracted with an outside vendor to perform the obstruction ASAP.
The Inspection will be placed on the PM log and will be completed as required every 5 years. The maintenance director or designee will maintain the PM log.
3) The sprinkler head in room 416 was cleaned immediately.
The cleaning of the sprinkler heads has been added to the cleaning check list for the housekeeping staff.
Random audits of the sprinkler heads will be completed quarterly by the Housekeeping supervisor or designee and the results brought to the QAPI committee.
4) The escutchens were replaced immediately on the 2nd floor nursing station, the 1st floor central supply storage room and the 1st floor kitchen.
All staff will be educated on recognizing the visible parts of the sprinkler system and the need to have them replaced via a work order for maintenance.
Recognizing the visible parts of the sprinkler will be added to the Fire Safety training for new hires and annually for fire safety training.
Random audits of the sprinklers will be performed quarterly by the maintenance director or designee and the results brought to the QAPI committee.

NFPA 101 STANDARD Corridor - 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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure that corridor doors positively latched into the door frame, affecting 4 of 9 smoke zones within the facility.

Findings include:

1. Observations made on January 9, 2019, between 10:54 am and 1:57 pm, revealed doors that failed to positively latch into the door frame in the following locations:

a. 10:54 am, 4th floor, resident room # 401.
b. 1:05 pm, 3rd floor, resident room # 322.
c. 1:22 pm, 2nd floor, resident room # 209.
d. 1:40 pm, 2nd floor, resident room # 218.
e. 1:57 pm, 2nd floor, resident room # 222.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the doors that failed to latch in the above named locations.





 Plan of Correction - To be completed: 01/10/2019

The doors identified room 401, room 322, room 209, room 218, room 222 were realigned and latched positively on 1/10/2019.
All Health Center doors will be audited and any not latching will be immediately realigned to ensure latching.
Routine audits of fire safety doors will be performed on a monthly rotating basis by the maintenance director or designee. The reports will be reviewed by the QAPI committee quarterly.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain that smoke barrier walls were free of unsealed penetrations, in three of five levels.

Findings include:

1. Observation on January 9, 2019, between 10:40 am, and 1:50 pm, revealed unsealed penetrations of the smoke barrier walls in the following locations:

a. 10:50 am, 4th floor, above smoke doors by room 411 around wires.
b. 11:10 am, 4th floor, above smoke doors by room 433 around pipe and wires.
c. 11:20 am, 3rd floor pantry, above the door to dining room.
d. 12:50 pm, 3rd floor, above smoke doors by room 319 around MC cables.
e. 1:30 pm, 2nd floor pantry, section of wall removed for plumbing pipes, and numerous penetrations throughout the wall.
f. 1:50 pm, 2nd floor, above smoke doors by room 221, around bundle of wires.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019, at 2:50 pm, confirmed the unsealed penetrations of the smoke barrier walls.






 Plan of Correction - To be completed: 01/11/2019

The following unsealed penetrations have been sealed as of 1/11/2019 using a UL rated fire caulk product by 3m CP25WB/ fire caulk.
a) 4th floor above the smoke doors room 411 around the wires
b)4th floor above smoke doors by 433 around the pipe wires and door to dining room
c) the 3rd floor pantry door to the dining rom area
d) 3rd floor above smoke doors by 319 around MC cables
f)2nd floor above smoke doors of room 22 around a bundle of wires.
The 2nd floor pantry (e) the section of wall removed for pipe repair and the penetrations listed have been repaired with new dry wall and sealed with an approved through-penetration fire-stop system using a UL rated 3m CP25WB product.
Routine quarterly audits will be performed by the maintenance director or designee to check for any penetrations. The results of the audits will be forwarded to the QAPI committee.
Vendors who perform any repairs will have to report to PRHC maintenance prior to leaving to ensure all smoke barriers effected by the repair are free of penetrations per code.



NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting the entire facility.

Findings include:

1. Document review on January 9, 2019, at 8:45 am, revealed the facility did not have documentation showing that fire and smoke dampers were tested and inspected within the last four years.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019, at 2:50 pm, confirmed that documentation of a smoke damper test and inspection was not available.











 Plan of Correction - To be completed: 03/08/2019

PRHC did have the fire and smoke dampers inspected in 2016; we have contracted with the vendor to re issue the results of the inspection at cost, and will have these results ready to view upon re inspection.
PRHC maintenance director will maintain a PM log and have this information stored in the log, PRHC will be schedule re inspection for 2020.
NFPA 101 STANDARD HVAC - Any Heating Device: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.
HVAC - Any Heating Device
Any heating device, other than a central heating plant, is designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. If fuel fired, the device also:
* is chimney or vent connected.
* takes air for combustion from outside.
* provides for a combustion system separate from occupied area atmosphere.
19.5.2.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0522

Based on observation and interview, it was determined the facility failed to maintain heating units free of combustible materials, affecting 1 of 9 smoke zones within the facility.

Findings include:

1. Observation made on January 9, 2019, 1:20 pm, 2nd floor, revealed there was a large carpet pad resting against a heater unit inside resident room # 212.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed there was a carpet pad resting against a heater unit.



 Plan of Correction - To be completed: 03/08/2019

The floor mats; a safety device for injury prevention were removed from the wall heating unit of room 212.
The staff educator will complete education for all health center staff on the proper storage of floor mats when not in use.
random audits of rooms with floor mats will be performed weekly for 4 weeks, then monthly for 3 months, and results shared with the QAPI committee.
NFPA 101 STANDARD Fire Drills: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.
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.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly, for one of twelve required drills.

Findings include:

1. Document review on January 9, 2019, at 9:15 am, revealed the facility could not provide documentation that a fire drill had been conducted on the second shift, during the first quarter of 2018.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed there was no documentation that a fire drill had been conducted on the second shift, for the first quarter of 2018.







 Plan of Correction - To be completed: 03/08/2019

The fire drill plan has been set for the 2019 year; the plan is at least quarterly on each shift as required. If a drill date and time has to be adjusted for any reason the subsequent drill schedule will also be adjusted to ensure compliance.
The Security/ Safety office will maintain the monthly records and report to the QAPI committee on a quarterly basis.
NFPA 101 STANDARD Soiled Linen and Trash Containers: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.
Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0754

Based on observation and interview, it was determined the facility failed to properly store soiled linen receptacles greater than 32-gallons in capacity in a protected hazardous storage area, affecting 1 of 5 levels within the facility.

Findings include:

1. Observation on January 9, 2019, at 1:50 pm, revealed 5 filled 32 gallon soiled linen containers with a combined capacity of approximately 160 gallons, were being stored inside the 2nd floor spa room.

Interview at the exit conference with the Administrator and the Director of Plant Operations on January 9, 2019 at 2:50 pm, confirmed the soiled linen containers were being stored inside the 2nd floor spa room.




 Plan of Correction - To be completed: 03/08/2019

The soiled linen containers were immediately removed from the 2nd floor spa room, and placed past the fire doors in the cove of the corridor at the end of the service hallway.
The Nurse educator will educate all nursing staff to not placed any linen containers in the spa room.
The side by side trash and laundry receptacles will be emptied and the soiled linen and trash placed into the soiled utility room large receptacle. The empty carts stored past the double doors, void of any hazardous material for the next use.
Weekly audits of the spa rooms will be performed for 4 weeks, then monthly for 2 months and the results forwarded to the QAPI committee.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port