Nursing Investigation Results -

Pennsylvania Department of Health
LEHIGH VALLEY HOSPITAL TRANSITIONAL SKILLED UNIT
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LEHIGH VALLEY HOSPITAL TRANSITIONAL SKILLED UNIT
Inspection Results For:

There are  33 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.
LEHIGH VALLEY HOSPITAL TRANSITIONAL SKILLED UNIT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on October 10, 2019, at Lehigh Valley Hospital Transitional Skilled Unit, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 012702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on October 10, 2019, it was determined that Lehigh Valley Hospital Transitional Skilled Unit was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a seven story, Type II (222), fire resistive building, with a basement and rooftop mechanical spaces, that is fully sprinklered.

Note: the transitional care unit is located on the sixth floor of the main hospital building.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in one location, affecting one of six floors.

Findings include:

1. Observation on October 10, 2019, at 10:50 a.m., revealed spray fireproofing missing from a portion of the ceiling assembly within the sixth floor mechanical room.

Exit interview on October 10, 2019, between 12:00 p.m. and 12:15 p.m., with the facility administrator, confirmed the building construction deficiency.




 Plan of Correction - To be completed: 11/13/2019

1. Quote obtained for duct demolition and correction on 10/24/2019. Work will be completed by 11/13/2019.

2. Upon completion of work, Engineering department will inspect the final installation and report back to the unit QAPI committee.

3. Third party inspection of fire proofing completed annually. (June 2019).

4. Director of Engineering/Designee will continue to monitor the integrity of the fireproofing throughout the unit on a random basis.

5. QAPI Committee will recommend additional audits as needed.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of six floors.

Findings include:

1. Observation on October 10, 2019, at 11:00 a.m., revealed an escutcheon plate was missing from the sprinkler head assembly within the sixth floor PT/OT Speech Dept. storage room.

Exit interview on October 10, 2019, between 12:00 p.m. and 12:15 p.m., with the facility administrator, confirmed the sprinkler system deficiency.



 Plan of Correction - To be completed: 11/13/2019

1. Escutcheon plate replaced on 10/18/2019.

2. Director of Engineering/Designee will continue to monitor sprinkler heads on a random basis for compliance. Director of Engineering will report back to QAPI Committee.

3. LVHN Fire Marshall completes inspection in conjunction with Kistler O'Brien annually.

4. QAPI Committee will monitor and recommend additional audits as necessary.
NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain heating, ventilation, and air conditioning in one location, affecting two of six floors.

Findings include:

1. Observation on October 10, 2019, at 11:15 a.m., revealed the exhaust duct, located within the utility access closet, at the sixth floor level, lacked a fire damper where penetrating the floor slab assembly.

Exit interview on October 10, 2019, between 12:00 p.m. and 12:15 p.m., with the facility administrator confirmed the heating, ventilation, and air conditioning deficiency.



 Plan of Correction - To be completed: 11/13/2019

1. Quote obtained for duct demolition and correction on 10/24/2019. Work will be completed by 11/13/2019.

2. Upon completion of work, Engineering department will inspect the final installation and report back to the unit QAPI committee.

3. Director of Engineering/Designee will continue to monitor on a random basis and report back to the QAPI Committee.

3. QAPI Committee will monitor and continue to recommend additional audits as needed.

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