Pennsylvania Department of Health
ALLIED SERVICES TRANSITIONAL REHABILITATION UNIT
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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ALLIED SERVICES TRANSITIONAL REHABILITATION 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 February 24, 2025, at Allied Services Transitional Rehabilitation Unit, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID# 01690201
Component 01
Transitional Rehabilitation Unit

Based on a Medicare/Medicaid Recertification Survey completed on February 24, 2025, it was determined that Allied Services Transitional Rehabilitation 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 483.70(a).

This is a three story, Type II (000), unprotected, noncombustible building, with a partial basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

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 - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations, affecting six of six smoke compartments.
Findings include:
1. Observation on February 24, 2025, at 9:45 a.m., revealed the facility exceeded the maximum allowable story height for the type of construction.
Interview at exit with the Assistant VP of Facilities on February 24, 2025, at 12:15 p.m., confirmed the building exceeded the maximum allowable story height.

Plan of Correction - To be completed: 04/30/2025

The facility submitted an FSES in accordance with the 2012 Life Safety Code to PA DOH on May 31, 2017. Approval was received on the FSES from the Center for Medicare and Medicaid Services (CMS) on August 4, 2017 to ensure ongoing compliance with deficiency K 0161.

BDA Healthcare Architects will conduct an updated FSES of the building in accordance with 2012 Life Safety Code.

The new FSES will be submitted to the Supervisor Williamsport Field Office Division of Safety Inspection.

NFPA 101 STANDARD Number of Exits - Story and Compartment:

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: MAIN - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations, affecting six of six smoke compartments.
Findings include:
1. Observation on February 24, 2025, at 12:00 p.m., basement, revealed the facility failed to provide two acceptable means of egress for each floor, or fire section of the building, in one location, affecting one of six smoke compartments.
Interview at exit with the Assistant VP of Facilities on February 24, 2025, at 12:15 p.m., confirmed the basement lacked a second, acceptable means of egress.

NFPA 101 STANDARD Corridor - Doors:

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.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one location, affecting one of six compartments.

Findings include:

1. Observation on February 24, 2025, at 11:15 a.m., 3rd floor, revealed the Multipurpose Room door, failed to latch into frame when tested.

Interview at exit with the Assistant VP of Facilities on February 24, 2025, at 12:15 p.m., confirmed the corridor failed to latch.

Plan of Correction - To be completed: 03/14/2025

The 3rd Floor Multipurpose Room door will be adjusted to ensure positive latching is achieved and maintained.

The facilities computerized maintenance management system will generate a work order to check the door monthly, to verify positive latching.

NFPA 101 STANDARD HVAC:

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 - Component: 01 - Tag: 0521

Based on documentation and interview, the facility failed to maintain Heating,Ventilating, and Air Conditioning (HVAC) system ductwork through fire-rated walls throughout the facility.

Findings include:

1. Observation on February 24, 2025, at 11:00 a.m., revealed the HVAC fire/smoke dampers have not been exercised in the past 4 years, Last documented 12/2020-1/2021.

Interview at exit with the Assistant VP of Facilities on February 24, 2025, at 12:15 p.m., confirmed the fire/smoke dampers have not been exercised in the last 4 years.

Plan of Correction - To be completed: 04/25/2025

All HVAC fire/smoke dampers will be tested as per policy. All findings will be documented. Any corrective actions necessary as identified through the testing will be taken.

The facility computerized work order system preventative maintenance work order system will generate a work order to test fire/smoke dampers.

The Assistant Director of Facilities will be responsible for ensuring that fire/smoke damper testing in performed during the appropriate time intervals. The assistant director will also be responsible to ensure that all documentation is compiled and any necessary corrective actions are completed on time.

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