QA Investigation Results

Pennsylvania Department of Health
DEVEREUX PA ADULT SERVICES - SPRUCE
Building Inspection Results

DEVEREUX PA ADULT SERVICES - SPRUCE
Building Inspection Results For:


There are  15 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on January 22, 2019, at Devereux PA Adult Services - Spruce, 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

Facility ID #04261100
Component 01
Main Building

Based on a Medicaid Recertification Survey completed on January 22, 2019, it was determined that Devereux PA Adult Services - Spruce was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a two-story, Type V (000), unprotected wood frame structure, with a basement, which is not sprinklered.

State plans approved as Prompt.



Plan of Correction:




NFPA 101 STANDARD
Stairways and Smokeproof Enclosures

Name - MAIN BUILDING 01 Component - 01
Stairways and Smokeproof Enclosures
2012 EXISTING (Prompt)
Interior stairs used as a primary means of escape shall be enclosed with fire barriers in accordance with Section 8.3 having a minimum 1/2-hour fire resistance rating. Stairs shall comply with 7.2.2.5.3. The entire primary means of escape shall be arranged so that it is not necessary for the occupants to pass through a portion of a lower story unless that route is separated from all spaces on that story by construction having not less than a 1/2-hour fire resistance rating. In buildings of construction other than Type II (000), Type III (200), or Type V (000), the supporting construction shall be protected to afford the required fire resistance rating of the supported wall.
1. Stairs that connect a story at street level to only one other story shall be permitted to be open to the story that is not at street level.
2. In Prompt Evacuation Capability facilities, stair enclosures shall not be required in buildings of three or fewer stories protected throughout by an approved automatic sprinkler system in accordance with 33.2.3.5 that uses quick response or residential sprinklers. This exception shall be permitted only if a primary means of escape from each sleeping area still exists that does not pass through a portion of a lower floor, unless that route is separated from all spaces on that floor by construction having a 1/2-hour fire resistance rating.
3. In Prompt Evacuation Capability facilities, stair enclosures shall not be required in buildings of two or fewer stories with not more than eight residents and are protected by an approved automatic sprinkler system in accordance with 33.2.3.5 that uses quick-response or residential sprinklers. The requirement found at section 33.2.2.3.3, 33.2.3.4.6 or 33.2.3.4.3.7 are not permitted to be used in this instance.
4. In Prompt Evacuation Capability facilities, of three or fewer stories protected by an approved automatic sprinkler system in accordance with 33.2.3.5, stairs shall be permitted to be open at the topmost story only. The entire primary means of escape of which the stairs are a part shall be separated from all portions of lower stories.
Stairs shall comply with 7.2.2 unless otherwise specified in Chapter 33. Winders complying with 7.2.2.2.4 shall be permitted. Exterior stairs shall be protected against blockage caused by fire within the building.
33.2.2.4, 33.2.2.6

Observations:

Based on observation and interview, it was determined the facility failed to maintain the stairway doors to positively latch, on one of two floors within the component.

Findings include:

1. Observation on January 22, 2019, at 2:00 PM revealed the door, at the top of the stairway, failed to positively latch.

Interview at the time of the exit conference with the Facilities Director on January 22, 2019, at 2:40 PM confirmed the door failed to positively latch.




Plan of Correction:

The Maintenance Manager will ensure that the door at the top of the stairway is repaired and adjusted so that it positively latches when closing. This was completed January 23, 2019.

All other facility doors were reviewed at the time of the survey and no other problems were identified.

The Program Supervisor will insure that all doors in the facility are checked for proper operation and positive latch at the time of the fire drill each month and document it on the monthly fire drill report. The fire drill report will be reviewed by the Administrative Supervisor who will ensure the doors were checked, the outcome documented, and any problems found are immediately reported and effectively resolved. The Program Administrator will document her review by signing and dating the fire drill report.



NFPA 101 STANDARD
Corridor - Doors

Name - MAIN BUILDING 01 Component - 01
Corridor - Doors
Doors shall meet all of the following requirements:
1. Doors shall be provided with latches or other mechanisms suitable for keeping the door closed.
2. No doors shall be arranged to prevent the occupant from closing the door.
3. Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 in buildings other than those protected throughout by an approved automatic sprinkler system in accordance with 33.2.3.5.
Door assemblies with leaves required to swing in the direction of egress travel are inspected and tested annually per 7.2.1.15.
33.2.3.6.4, 33.7.7

Observations:

Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, on one of two floors within the component.

Findings include:

1. Observation on January 22, 2019, at 2:40 PM revealed the door, to Room 207, did not latch into the frame.

Interview at the time of the exit conference with the Facilities Director on January 22, 2019, at 2:40 PM confirmed the door failed to positively latch.





Plan of Correction:

The Maintenance Manager will ensure that the door to room 207 is repaired and adjusted so that it latches into the frame. This was completed January 23, 2019.

All other facility doors were reviewed at the time of the survey and no other problems were identified.

The Program Supervisor will insure that all doors in the facility are checked for proper operation and positive latch at the time of the fire drill each month and document it on the monthly fire drill report. The fire drill report will be reviewed by the Administrative Supervisor who will ensure the doors were checked, the outcome documented, and any problems found are immediately reported and effectively resolved. The Program Administrator will document her review by signing and dating the fire drill report.