QA Investigation Results

Pennsylvania Department of Health
DIVINE PROVIDENCE VILLAGE
Building Inspection Results

DIVINE PROVIDENCE VILLAGE
Building Inspection Results For:


There are  32 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 April 30, 2019, at Divine Providence Village, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.



Plan of Correction:




Initial Comments:
Name - PROMPT (YELLOW COTTAGE) NOW SLOW 4/25/2013 Component - 01

Facility ID #04811100
Component 01
Yellow Cottage

Based on a Medicaid Recertification Survey completed on April 30, 2019, at Divine Providence Village - Yellow Cottage, it was determined there were no deficiencies identified under the 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 one-story, Type III (211), protected ordinary structure, which is fully sprinklered.

State Plans approved as Prompt.



Plan of Correction:




Initial Comments:
Name - SLOW (ORANGE COTTAGE) Component - 02

Facility ID #04811100
Component 02
Orange Cottage

Based on a Medicaid Recertification Survey completed on April 30, 2019, at Divine Providence Village - Orange Cottage, it was determined there were no deficiencies identified under the 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 one-story, Type III (211), protected ordinary structure, which is fully sprinklered.

State Plans approved as Slow.



Plan of Correction:




Initial Comments:
Name - SLOW (BLUE COTTAGE) Component - 03

Facility ID #04811100
Component 03
Blue Cottage

Based on a Medicaid Recertification Survey completed on April 30, 2019, it was determined that Divine Providence Village - Blue Cottage, 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 one-story, Type III (211), protected ordinary structure, which is fully sprinklered.

State Plan approved as Slow.




Plan of Correction:




NFPA 101 STANDARD
General Requirements - Other

Name - SLOW (BLUE COTTAGE) Component - 03
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:

Based on observation and interview, it was determined the facility failed to ensure portable oxygen cylinders were secured, affecting 1 of one level.

Findings include:

1. Observation made on April 30, 2019, at 12:03 pm, revealed there was one freestanding E-type portable oxygen cylinder housed on the back porch of the building.

Interview at the exit conference with the Program Director, Assistant Director of Operations and the Director of Maintenance on April 30, 2019, at 2:45 pm, confirmed there was one unsecured oxygen cylinder.
~Refer to NFPA 99, 2012 Edition Sections 11.3.1, 5.1.3.3.2(7).







Plan of Correction:

The one freestanding E-type portable oxygen cylinder tank was secured on the day of inspection

The Director of Nursing will conduct training with the Management team and Staff on the importance of securing E-type portable oxygen cylinder tanks.

The Director of Nursing of and the Health Care Coordinators will conduct a visual inspection of each cottage to ensure all oxygen tanks are secured properly




NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - SLOW (BLUE COTTAGE) Component - 03
Sprinkler System - Maintenance and Testing
2012 EXISTING (Prompt)
NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, are inspected, tested and maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, are inspected, tested and maintained in accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section 13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20 years (NFPA 25, section 5.3.1.1.1.2).
11. A representative sample of dry pendant sprinklers are tested at 10 years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25, section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system. __________________________________
(Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.)
33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation and interview, it was determined the facility failed to ensure the automatic sprinkler system and its components were maintained free of obstructions, affecting one of one level within the component.

Findings include:

1. Observation made on April 30, 2019, at 12:12 pm, revealed inside the Med Room, there was a sprinkler with debris on it.

Interview at the exit conference with the Program Director, Assistant Director of Operations and the Director of Maintenance on April 30, 2019, at 2:45 pm, confirmed the sprinkler with debris.






Plan of Correction:

The ceiling sprinkler in the Blue Med room was corrected on May 1, 2019. The Maintenance team on May 1, 2019 wiped the sprinkler head down with a damp cloth to remove any dust or debris.

The Director of Maintenance will conduct training with the Management team and Staff on the importance of timely repair of any issues with sprinkler heads. Target Date: July 10, 2019

The Facilities Department will conduct a walk-through of each of the residential buildings to visually inspect the cleanliness of the sprinkler heads by June 1, 2019.




Initial Comments:
Name - PROMPT (GREEN COTTAGE) Component - 04

Facility ID #04811100
Component 04
Green Building

Based on a Medicaid Recertification Survey completed on April 30, 2019, it was determined that Divine Providence Village - Green Cottage, 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 one-story, Type III (211), protected ordinary structure, which is fully sprinklered.

State Plan approved as Prompt.



Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - PROMPT (GREEN COTTAGE) Component - 04
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation and interview, it was determined the facility failed to ensure fire alarm system components were protected, affecting the entire component.

Findings include:

1. Observation made on April 30, 2019, at 11:30 am, revealed inside the fire alarm panel room, there was an open junction box above the main fire alarm panel, exposing electronic wiring and electronic components that serve the fire alarm system.

Interview at the exit conference with the Program Director, Assistant Director of Operations and the Director of Maintenance on April 30, 2019, at 2:45 pm, confirmed the open junction box.





Plan of Correction:

The open junction box above the main fire alarm panel was corrected on May 3, 2019. Sentry Alarm company was brought out on May 3, 2019 to install the correct junction box that would fit all of the electronic wiring and a junction box cover was installed.

The Director of Facilities and the Maintenance team will conduct a visual inspection to ensure there is no other open junction boxes throughout the cottages

Maintenance checks will continue to be conducted monthly by Maintenance staff and reviewed by the Director of Maintenance to ensure they are completed as outlined and appropriate follow up occurs.




Initial Comments:
Name - IMPRACTICAL (PURPLE COTTAGE) Component - 05

Facility ID #04811100
Component 05
Purple Cottage

Based on a Medicaid Recertification Survey completed on April 30, 2019, at Divine Providence Village - Purple Cottage, it was determined there were no deficiencies identified under the 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 one-story, Type III (211), protected ordinary structure, which is fully sprinklered.

State Plan approved as Impractical.



Plan of Correction:




Initial Comments:
Name - SLOW (RED COTTAGE) Component - 06

Facility ID #04811100
Component 06
Red Building

Based on a Medicaid Recertification Survey completed on April 30, 2019, at Divine Providence Village - Red Cottage, it was determined there were no deficiencies identified under the 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 one-story, Type III (211), protected ordinary structure, which is fully sprinklered.

State Plan approved as Slow.



Plan of Correction: