QA Investigation Results

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

DON GUANELLA HOMES AT ROLLING
Building Inspection Results For:


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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on July 25, 2018, it was determined that Don Guanella Homes At Rolling Road was not in compliance with the requirements of 42 CFR 483.475.



Plan of Correction:




483.475(b)(8) STANDARD
Roles Under a Waiver Declared by Secretary

Name - Component - --
[(b) Policies and procedures. The [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 at least annually. At a minimum, the policies and procedures must address the following:]

(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

*[For RNHCIs at 403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Observations:

Based on document review and interview, it was determined the facility failed to provide policy and procedure documentation concerning the role of the ICF/IID facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials, affecting the entire facility.

Findings include:

1. Document review on July 25, 2018, between 9:00 am and 10:15 am, revealed the facility could not provide Emergency Preparedness Plan policy and procedure documentation concerning the Roles under a Waiver Declared by Secretary.

Interview at the exit conference with the Director of Facilities, the Facility House Manager, and the Maintenance Supervisor on July 25, 2018, at 9:50 am, confirmed the Emergency Preparedness plan did not include policy and procedure documentation concerning the Roles under a Waiver Declared by Secretary.








Plan of Correction:

The facility's Emergency Preparedness plan was further revised to include its role under a waive declared by the Secretary in accordance with section 1135. This would include procedures to ensure care and treatment in an alternate care site as deemed necessary by officials. Date of this revision, 8/2/2018.
The emergency plan will be reviewed and trained annually and documentation kept on file.


Initial Comments:
Name - DON GUANELLA HOMES AT ROLLING Component - 01

Facility ID # 24411101
Component 01
Main Building

Based on a Medicaid Recertification Survey completed on July 25, 2018, at Don Guanella Homes At Rolling Road, 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 construction, with a basement, which is fully sprinklered.

State plans approved as Impractical.




Plan of Correction: