Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on March 25, 2024, it was determined that Valley Community Services-West Sunbury was not in compliance with the requirements of 42 CFR 483.475.
Plan of Correction:
483.475(a)(4) STANDARD
Local, State, Tribal Collaboration Process
Name - Component - --
§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]
(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *
* [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Based on document review and interview, the facility failed to meet emergency preparedness plan requirements for one of one emergency preparedness plan.
Findings include:
Document review on March 25, 2024, at 10:10 a.m., revealed the facility failed to provide preparedness documentation that detailed local agency contact during an emergency.
Interview with the house manager on March 25, 2024, at 10:10 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.
Plan of Correction:A letter was drafted and sent on April 3, 2024 to the West Sunbury Fire Department and the PA State Police Barracks in Butler, PA. The letter contains information on the location, phone number, house structure and number of individuals and mobility of the individuals in the home. The contact number of the Program Manager was also provided if they had any questions.
All Managers will be trained by April 12, 2024, to initiate local agency contact by sending correspondence to their local fire and police departments. The letter should contain information on the location, phone number, house structure and number of individuals and mobility of the individuals in the home. The Program Manager will be provided in the letter if they should have any questions. The Program Manager's will be responsible each year for maintaining local agency contacts.
483.475(b)(1) STANDARD
Subsistence Needs for Staff and Patients
Name - Component - --
§403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1)
[(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:
(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.
*[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
Observations:
Based on document review and interview, the facility failed to meet emergency preparedness plan requirements for one of one emergency preparedness plan.
Findings include:
Document review on March 25, 2024, at 10:14 a.m., revealed the following facility policies were inaccurate or site-specific at the time of the survey:
A. (10:14 a.m.) Facility's loss of utilities plan was inaccurate. The policy stated that generators automatically start following electrical failure. The facility does not currently have a generator installed;
B. (10:14 a.m.) The facility's emergency sewage and waste disposal plan was inaccurate. The policy stated that portable toilets would be used in the event of waste disposal failure. The facility did not have portable toilets on-site.
Interview with the house manager on March 25, 2024, at 10:14 a.m., confirmed the facility's policies will be updated and site-specific.
Plan of Correction:A. The Emergency Preparedness Plan was reviewed for West Sunbury ICF / ID and the policy was revised on 4/3/24 to eliminate inaccuracies. The policy states that staff will notify the supervisor or person on call. The supervisor or person on call will take the appropriate action to ensure a safe environment, which may include relocation. At this time the West Sunbury ICF does not have a generator but in the event that one is installed. VCS will follow the proper codes, policies and procedures to maintain a generator.
B. The Emergency Preparedness Plan was reviewed for West Sunbury ICF / ID and the policy was revised on 4/3/24 to eliminate inaccuracies. The policy states that staff will notify the supervisor or person on call. The supervisor or person on call will take the appropriate action to ensure a safe environment. The old policy that stated "In the event of a plumbing shut down, portable toilets will be utilized and waste disposed in hazard bags." has been removed from the policy and in the event of a plumbing shut down, the West Sunbury ICF Home may be relocated. Emergency Preparedness Plans will be reviewed and revised by 4/12/24 to eliminate inaccuracies for all Valley Community Services ICF homes.
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID #22321100
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on March 25, 2024, it was determined that Valley Community Services-West Sunbury 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 framed building, with a basement and attached garage, that is fully sprinklered. The garage is separated and sprinklered.
State plans approved as Slow.
Plan of Correction:
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - MAIN BUILDING 01 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 document review, observation, and interview, the facility failed to meet fire alarm system testing and maintenance requirements for one of one system.
Findings include:
1. Document review on March 25, 2024, at 9:44 a.m., revealed the heat detectors were not functionally tested during the annual fire alarm inspection, dated March 7, 2024. The facility was unable to provide documentation explaining why the detectors were not tested.
Interview with the house manager on March 25, 2024, at 9:44 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.
2. Observation on March 25, 2024, at 10:33 a.m., revealed the pull station was not located in a conspicuous, unobstructed location. The pull station was located partially behind the refrigerator.
Interview with the house manager on March 25, 2024, at 10:33 a.m., confirmed the deficiency and moved the refrigerator to clearly expose the pull station.
Plan of Correction:1. Aven was contacted on 3/28/24 and visited the West Sunbury ICF on 4/4/24. On 4/4/24 all heat detectors were functionally / circuit tested by AVEN and are in working order. AVEN agreed to complete functional testing of the heat detectors during annual fire alarm inspections and provide documentation of the functional testing.
2. The current pull station is located in a conspicuous, unobstructed location. The pull station will be relocated to an adjacent location beside the egress door. This will be completed by 6/14/24.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING 01 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 document review and interview, the facility failed to meet sprinkler system testing and maintenance requirements for one of one system.
Findings include:
Document review on March 25, 2024, at 9:58 a.m., revealed the facility failed to provide annual anti-freeze testing documentation.
Interview with the house manager on March 25, 2024, at 9:58 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.
Plan of Correction:Aven was contacted on 3/28/24 and visited the West Sunbury ICF on 4/4/24. On 4/4/24 all annual antifreeze testing was completed by AVEN without any problems noted. Testing documentation will be provided via e-mail and on site for the West Sunbury ICF. AVEN will complete annual antifreeze testing and provide documentation and this will be ongoing annually.
NFPA 101 STANDARD
Utilities - Gas and Electric
Name - MAIN BUILDING 01 Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NPFA 70, National Electric Code.
32.2.5.1, 33.2.5.1, 9.1.1, 9.1.2
Observations:
Based on observation and interview, the facility failed to meet NFPA 70 requirement at one of over ten outlets.
Findings include:
Observation on March 25, 2024, at 10:14 a.m., revealed the kitchen area had an outlet located within six feet of the sink not protected by a ground fault circuit interrupter (GFCI).
Interview with the house manager on March 25, 2024, at 10:14 a.m., confirmed the outlet was not GFCI-protected.
Plan of Correction:On 3/28/24 a Maintenace request was submitted by the Operations Director and Maintenance is scheduled to install a GFCI outlet in the kitchen area that is within 6 feet from the water source which was completed on 4/3/24. All Program Managers will be trained by 4/12/24 ensuring that outlets are GFCI are protected around water sources as per NFPA 70 Requirement.
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