QA Investigation Results

Pennsylvania Department of Health
ELWYN WECHSLER
Building Inspection Results

ELWYN WECHSLER
Building Inspection Results For:


There are  14 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on August 2, 2018, at Elwyn Wechsler, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.



Plan of Correction:




Initial Comments:
Name - WECHSLER RESIDENTIAL BUILDING (ELWYN MEDIA CAMPUS) Component - 01

Facility ID# 22921101
Component 01
Wechsler Building

Based on a Medicaid Recertification Survey completed on August 2, 2018, it was determined that Elwyn Wechsler 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 II (000), unprotected non-combustible structure, with three attic spaces, which is fully sprinklered.




Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Notification

Name - WECHSLER RESIDENTIAL BUILDING (ELWYN MEDIA CAMPUS) 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 document review and interview, it was determined the facility failed to ensure the fire alarm system had remote annunciation to an approved central station, affecting the entire component.

Findings include:

1. Document review on August 2, 2018, at 10:00 am, revealed the facility fire alarm system did not transmit a signal to the local fire department or an off-site central monitoring company.

Interview at the exit conference with the Unit Manager and Maintenance Manager on August 2, 2018, at 11:00 am, confirmed the fire alarm did not report to a central station.





Plan of Correction:

Per requirements of the 2012 Life Safety Code enforced on 8/2/18 Elwyn is requesting an updated Fire Safety Evaluation System (FSES) for Wechsler.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - WECHSLER RESIDENTIAL BUILDING (ELWYN MEDIA CAMPUS) Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
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 automatic fire sprinkler system components in reliable operating condition, affecting two of three smoke compartments within this facility.

Findings include:

1. Observation made on August 2, 2018, at 10:55 am, revealed that the electric fire pump room door failed to close completely and positively latch into the frame when tested.

Interview at the exit conference with the Unit Manager and Maintenance Manager, on August 2, 2018, at 11:00 am, confirmed the door failed to positively latch.

2. Observation made on August 2, 2018, at 10:00 am, revealed the side wall sprinkler head, within A-wing room 33, was missing escutcheon ring.

Interview at the exit conference with the Unit Manager and Maintenance Manager, on August 2, 2018, at 11:00 am, confirmed the missing escutcheon ring.







Plan of Correction:

Observation #1 - Work Order (WO) # 100514 has been issued to correct this finding. Maintenance will make repairs / adjustments needed to the door on the Fire Pump Room door to bring it into compliance with the regulations and standards stated in the survey summary. Director of Buildings & Grounds will review door regulations with maintenance staff. Maintenance will issue regular door inspections work orders to confirm that these standards are being met. Door inspection WO will be completed on a quarterly schedule. Director of Buildings & Grounds is responsible for seeing this is done. DOC 9-28-18

Observation #2: WO#100513 has been issued to correct this finding. Maintenance will install a new escutcheon in room #33 on A-side to bring it into compliance with the regulations stated in the survey summary. Director of Buildings & Grounds will review sprinkler regulations with maintenance staff. Maintenance will issue regular inspections work orders for the sprinkler systems to confirm these standards are being met. Sprinkler Inspection WO will be completed on a quarterly schedule. Director of Buildings & Grounds is responsible for seeing this is done. DOC 9-28-18



NFPA 101 STANDARD
Portable Fire Extinguishers

Name - WECHSLER RESIDENTIAL BUILDING (ELWYN MEDIA CAMPUS) Component - 01
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers for immediate use in one location, affecting one of three smoke compartments.

Findings include:

1. Observation made on August 2, 2018, at 10:30 am, revealed the portable fire extinguisher cabinet handle was broken limiting access to the extinguisher in the A-wing corridor, outside of room 1.

Interview at the exit conference with the Unit Manager and Maintenance Manager on August 2, 2018, at 11:00 am, confirmed the obstruction to access to the extinguisher.








Plan of Correction:

Work Order (WO) # 100516 has been issued to correct this finding. Maintenance will replace broken door handle on cabinet holding the fire extinguisher to bring it into compliance with the regulations and standards stated in the survey summary. Campus Safety Director will review Fire Extinguisher and Cabinet Inspection regulations with Campus Safety Officers. Campus Safety will do regular inspections on fire extinguishers and cabinets. These inspections will be done on a monthly basis. Director of Campus Safety is responsible for seeing this is done.
DOC 9/28/18