QA Investigation Results

Pennsylvania Department of Health
DON GUANELLA HOMES AT BETHEL
Building Inspection Results

DON GUANELLA HOMES AT BETHEL
Building Inspection Results For:


There are  5 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on June 14, 2018, it was determined that Don Guanella Homes at Bethel 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 a review of the facilities Emergency Preparedness (EP) Plan, it was determined the plan was not based on a documented, facility-based and community-based risk assessment.

Findings include:

1. Interview and documentation review on June 14, 2018, between 8:30 a.m. and 9:30 a.m., revealed that a facility-based and community-based risk assessment using an all hazards approach was not included in the EP Plan.

Interview at the exit conference with the Divisional Maintenance Manager on June 14, 2018, at 9:30 am, confirmed the risk assessment was not included in the EP Plan.

















Plan of Correction:

The EP plan included a risk assessment dated 4/13/2018 and was available at time of survey and remains current in the EP plan.

A full scale community based drill was conducted on 6/20/18 and 6/21/18. A de-debriefing of the 2 day( Delaware County) drill was conducted on 6/22/18 which included our facility participation in "medication pick up" for both residents and staff. This debriefing will be kept on file and included in our updated risk assessment. Additionally, our facility will participate the Delaware County de-briefing on 8/1/18.
All signature sheets for participation will be kept on file.
The facility emergency preparedness plan will be reviewed annual and a record of this review will be kept on file.



Initial Comments:
Name - DON GUANELLA HOME @ BETHEL Component - 01

Facility ID #24181101
Component 01
Main Building

Based on a Medicaid Recertification Survey completed on June 14, 2018, at Don Guanella Homes at Bethel, it was determined there were no deficiencies identified under the 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.

Approved with an Impractical level of evacuation difficulty.



Plan of Correction: