Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on March 29, 2022, at Elwyn Of Pennsylvania And Delaware - Sun Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - SUN CENTER 8-BED ICF& PHOENIX HALL Component - 01
Facility ID# 17841101
Component 01
Sun Center & Phoenix Hall
Based on a Medicaid Recertification Survey completed on March 29, 2022, it was determined Elwyn Of Pennsylvania And Delaware - Sun Center 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 construction, which is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Fire Alarm System - Notification
Name - SUN CENTER 8-BED ICF& PHOENIX HALL Component - 01
Fire Alarm - Notification
2012 EXISTING
Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals.
In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire.
19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1)
Observations:
Based on observation, document review and interview, it was determined the facility failed to maintain required transmission of the fire alarm system, affecting the entire facility.
Findings include:
1. Observation and document review on March 29, 2022, between 9:00 a.m. and 11:45 a.m., revealed the facility's fire alarm system does not transmit an alarm to the local fire department, a central monitoring station located off-site or an approved Proprietary Supervising Station. During a test of the fire alarm system, the alarm transmitted to the facility's front security desk located in the Administration Building.
Exit Interview with the Director of Maintenance on March 29, 2022, at 12:00 p.m., confirmed the fire alarm system does not transmit through an approved means.
Plan of Correction:Per requirements of the 2012 Life Safety Code enforced on 3/29/2022. Elwyn is requesting an updated Fire Safety Evaluation System (FSES). Elwyn is requesting DOH conduct the FSES.
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