QA Investigation Results

Pennsylvania Department of Health
COMMUNITY SERVICES - HANS HERR
Building Inspection Results

COMMUNITY SERVICES - HANS HERR
Building Inspection Results For:


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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on May 13, 2019, at Community Services - Hans Herr, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.


Plan of Correction:




Initial Comments:
Name - MAIN BUILDING 01 Component - 01

Facility ID# 10631100
Component 01
Main Building

Based on a Medicaid Recertification Survey completed on May 13, 2019, it was determined that Community Services - Hans Herr was not in compliance with the following requirements of the Life Safety Code for 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 V (000), unprotected wood frame structure, with a basement, which is fully sprinklered.

State plans approved as impractical.



Plan of Correction:




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 resist the passage of smoke, and to be free of impediments to closing, in one of one smoke zone within the component.

Findings include:

1. Observation on May 13, 2019, at 10:15 AM revealed the door frame to Bedroom 3 lacked a door stop, on the latch side, and exceeded a half inch gap.

Interview with the Director on May 13, 2019, at 10:15 AM confirmed the door exceeded the allowed gap margin.


2. Observation on May 13, 2019, at 10:30 AM revealed the doors to Bedrooms 1 and 5 overlapped when both were fully open, resulting in the doors not being able to be closed.

Interview with the Director on May 13, 2019, at 10:30 AM confirmed the doors were obstructing each other from closing.





Plan of Correction:

Community Services maintenance staff fixed the physical site problems on May 21, 2019.
For bedroom 3, a new slam strip was added.
For bedrooms 3 and 5, eye and hook closures were added to the doors to lock in place when needed for an individual in a wheelchair to come through.
The door of bedroom 3 was changed to swing out and the door of bedroom 5 was changed to swing in, so that both doors could be closed easily when fully open, at the same time.