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 May 15, 2024, 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 May 15, 2024, it was determined that Allied Services Transitional Rehabilitation Unit had deficiencies that have the potential for minimal harm as related to 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 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 May 15, 2024, at 9:45 a.m., revealed the facility exceeded the maximum allowable story height for the type of construction.

Interview at exit with the Facilities Manager and Assistant VP of Facilities on May 15, 2024, at 12:15 p.m., confirmed the building exceeded the maximum allowable story height.

Plan of Correction - To be completed: 06/15/2024

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 annually conducts an updated FSES of the building in accordance with 2012 Life Safety Code.

The new FSES is 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 May 15, 2024, at 9:45 a.m., 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 Facilities Manager and Assistant VP of Facilities on May 15, 2024, at 12:15 p.m., confirmed the basement lacked a second, acceptable means of egress.

Plan of Correction - To be completed: 06/15/2024

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 0241.

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

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

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