QA Investigation Results

Pennsylvania Department of Health
BARC MILFORD PLACE
Building Inspection Results

BARC MILFORD PLACE
Building Inspection Results For:


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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on May 8, 2019, it was determined that BARC Milford Place was not in compliance with the requirements of 42 CFR 483.475.





Plan of Correction:




483.475(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment

Name - Component - --
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

*[For LTC facilities at 483.73(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

*[For ICF/IIDs at 483.475(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at 418.113(a)(2):] (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

Observations:

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) plan which included a facility-based and community based risk assessment, utilizing an all-hazards approach, including missing residents, affecting the entire facility.

Findings include:

1. Document review on May 8, 2019, at 9:30 am, revealed the facility was unable to provide in its Emergency Preparedness plan, a documented facility-based and community-based risk assessment that included missing residents.

Interview with the House Manager and Maintenance Director on May 8, 2019, at 12:35 pm, confirmed the facility Emergency Preparedness plan did not include all required elements.










Plan of Correction:

BARC Developmental Services will revise the Emergency Preparedness to includes a documented facility-based and community-based risk assessment that includes missing residents. Annually each year in October the plan will be reviewed and updated. This review and update includes a recalculation of the facility-based and community-based risk for missing residents. The review and update will be completed the ICF Program Director.


Initial Comments:
Name - IMPRACTICAL Component - 01

Facility ID# 10911100
Building 01
Barc Milford Place

Based on a Medicaid Recertification Survey completed on May 8, 2019, it was determined that BARC Milford Place 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 V (000), unprotected wood frame structure, which is fully sprinklered.

State Plans approved as Impractical.





Plan of Correction:




NFPA 101 STANDARD
Corridor - Doors

Name - IMPRACTICAL 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 self-latch, affecting the entire facility.

Findings include:

1. Observation on May 8, 2019 at 11:40 am, revealed the corridor door to the resident room, next to the laundry room, did not positively self-latch into its frame.

Interview with the House Manager and Maintenance Director on May 8, 2019, at 12:35 pm, confirmed the door failed to positively self-latch.







Plan of Correction:

The door will be adjusted to ensure proper closer. the doors will be checked monthly by maintenance dept to make sure all are operational .