Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on December 18, 2023, at Elwyn Of Pennsylvania And Delaware - Chichester, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - ELWYN CHICHESTER AVE Component - 01
Facility ID# 20881101
Component 01
Based on a Medicaid Recertification Survey completed on December 18, 2023, it was determined that Elwyn Of Pennsylvania And Delaware - Chichester Avenue 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, with a basement, which is fully sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
Means of Egress - General
Name - ELWYN CHICHESTER AVE Component - 01
Means of Escape - General
2012 EXISTING
Designated means of escape shall be continuously maintained clear of obstructions and impediments to full instant use in the case of fire or emergency.
33.2.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain the means of egress free of hazards, affecting 1 of two levels.
Findings Include:
1. Observation made on December 18, 2023, between 10:49 a.m. and 11:30 a.m., revealed water along the floor within the basement.
Exit Interview with the Director of Maintenance, and the Director of Operations on December 18, 2023, at 11:30 a.m., confirmed the water hazard.
Plan of Correction:The Maintenance Department contacted the landscape contractor. The landscaper re-graded the ground around the exterior of the house to better direct ground water away from the house.
Maintenance will issue regular inspection Work Orders so that on a monthly basis the area will be checked by Elwyn Maintenance Department to confirm that there is no longer ground water getting into the basement.
The Maintenance Director will review these inspection Work Orders on a Quarterly basis to confirm these monthly checks are completed. The Director of Buildings & Grounds is responsible for seeing this is done.
NFPA 101 STANDARD
Vertical Openings - Enclosure
Name - ELWYN CHICHESTER AVE Component - 01
Vertical Openings - Enclosure
2012 EXISTING (Prompt)
Vertical openings shall be protected so as not to expose a primary means of escape. Vertical openings shall be considered protected if separated by smoke partitions in accordance with 8.2.4 that resist the passage of smoke from one story to any primary means of escape on another story. Smoke partitions shall have a fire resistance rating on not less than 1/2 hour. Any doors or openings to the vertical opening shall be capable of resisting fire for not less than 20 minutes.
Stairs shall be permitted to be open where complying with sections 33.2.2.4.6 or 33.2.2.7.
33.2.3.1.1 through 33.2.3.1.4
Observations:
Based on observation and interview, it was determined the facility failed to maintain protection of vertical openings between floors, affecting 2 of two levels.
Findings Include:
Observation made on December 18, 2023, at 10:46 a.m., revealed the basement stair door was offset in the door frame.
Exit Interview with the Director of Maintenance, and the Director of Operations on December 18, 2023, at 11:30 a.m., confirmed the vertical opening was not smoke tight.
Plan of Correction:Work Order #142682 was created to correct this finding. Maintenance will make repairs/adjustments needed to the door at the top of the basement stairs so that the vertical opening is smoke tight.
The Director of Buildings & Grounds will review door regulations with all maintenance staff. Maintenance will issue regular door inspection work orders to confirm that these standards are being met. Door inspection Work Orders will be completed on a quarterly schedule, so that all doors are checked on a quarterly basis.
The Director of Buildings & Grounds will review Door Work Orders on an annual basis to confirm these standards are being met. The Director of Buildings & Grounds is responsible for seeing this is done.
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - ELWYN CHICHESTER AVE Component - 01
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 maintain testing of fire alarm components, affecting 2 of two reports.
Findings Include:
1. Observation made on December 18, 2023, between 9:30 a.m. and 11:30 a.m., revealed the following fire alarm deficiencies:
a. Annual and Semi-annual reports were not available for 2023;
b. The Biennial Sensitivity report provided was dated July 14, 2020.
Exit Interview with the Director of Maintenance, and the Director of Operations on December 18, 2023, at 11:30 a.m., confirmed fire alarm testing had not been completed.
Plan of Correction:Maintenance contacted Rendin Alarm Company who completes the semi-annual fire equipment check and biennial sensitivity check of fire equipment for the missing reports and to have the required testing completed.
The Director of Building & Grounds will review the Regulations with Maintenance Staff and Rendin Alarm to make sure the Regulations are being met.
The Director of Buildings & Grounds will review records semi-annually to confirm these standards are met and paperwork has been completed and received. The Director of Buildings & Grounds is responsible for seeing this is done. All steps to be completed by 1/31/2024.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - ELWYN CHICHESTER AVE Component - 01
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 maintain the sprinkler system free of impediments, affecting 1 of approximately twelve rooms.
Findings Include:
Observation made on December 18, 2023, between 10:41 a.m., revealed storage within 18" of the sprinkler head inside resident room closet 4.
Exit Interview with the Director of Maintenance, and the Director of Operations on December 18, 2023, at 11:30 a.m., confirmed the sprinkler obstruction.
Plan of Correction:The storage in resident room #4 was removed by the Site Supervisor by 1/12/24.
All staff will be trained concerning storage 18 inches from ceiling by the Site Supervisors. The Senior Director added the lines " Items stored at least 18 inches below the ceiling" to Monthly Environmental Audit for checks in Dayroom, Laundry Rooms, Storage Rooms/Hallways, Bedrooms (including closets). This audit is completed monthly by Director or designee.
The Senior Director of ICFs is responsible for monitoring this corrective action.
All steps to be completed by 1/31/2024.
NFPA 101 STANDARD
Corridor - Doors
Name - ELWYN CHICHESTER AVE 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 with positive latching in their frames, affecting 1 of four bedrooms.
Findings Include:
Observation made on December 18, 2023, between 10:25 a.m., revealed the door to room 2 would not latch into its frame when closed.
Exit Interview with the Director of Maintenance, and the Director of Operations on December 18, 2023, at 11:30 a.m., confirmed the corridor door required adjustment.
.
Plan of Correction:Work Order #142685 was created to correct the door to room #2. Maintenance will make repairs/adjustments needed to the door for bedroom 2 to bring it into compliance.
The Director of Buildings & Grounds will review door regulations with maintenance staff. Maintenance will issue regular door inspection work orders to confirm that these standards are being met. Door inspection Work Orders will be completed on a quarterly schedule.
The Director of Buildings & Grounds will review Door Work Orders on an annual basis to confirm these standards are being met. The Director of Buildings & Grounds is responsible for seeing this is done.
All steps to be completed by 1/31/2024.
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