Nursing Investigation Results -

Pennsylvania Department of Health
BRANDYWINE HALL
Building Inspection Results

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BRANDYWINE HALL
Inspection Results For:

There are  37 surveys for this facility. Please select a date to view the survey results.

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BRANDYWINE HALL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN/CENTRAL - Component: 01 - Tag: 0000


Facility ID #023902
Component 01
Central Building

Based on a Relicensure Survey completed on October 9, 2019, it was determined that Brandywine Hall was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a three-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type:State only Deficiency.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: MAIN/CENTRAL - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the rating of common walls to non-conforming buildings, affecting one of three floors within the component.

Findings include:

1. Observation on October 9, 2019, at 11:36 AM revealed a penetration of the common wall around red wires, above the double doors in 1 Central, by Stair 3.

Interview with the Maintenance Supervisor on October 9, 2019, at 11:36 AM confirmed the unprotected penetration.



 Plan of Correction - To be completed: 11/20/2019

CORRECTIVE ACTION FOR AREAS AFFECTED:
Facility will correctly seal the penetrations above the double doors in 1 Central by Stair 3 with an approved through-wall penetration fire stop system W-L-4046.
OTHER AREAS AFFECTED:
Maintenance Director/Designee will audit nursing units to identify and correct any penetrations.
SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Maintenance Director/Designee will conduct random weekly audits of nursing units x4 weeks to identify and correct any penetrations identified during audit.
MONITORING OF CORRECTIVE ACTION:
Audit outcomes will be reviewed by the Interdisciplinary Team at the center's monthly Quality Assurance meeting for compliance. Action plan will be developed as needed.

NFPA 101 STANDARD Building Construction Type and Height:State only Deficiency.
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/CENTRAL - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements for the entire building, affecting three of three floors within the component.

Findings include:

1. Observation on October 9, 2019, between 10:00 AM and 1:00 PM revealed the facility is a three-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered. This type of construction is not permitted to be greater than two stories in height.

Interview with the Maintenance Supervisor on October 9, 2019, at 1:00 PM confirmed the construction type and height is not permitted in Health Care.



 Plan of Correction - To be completed: 11/20/2019

CORRECTIVE ACTION FOR AREAS AFFECTED:
Facility is working with engineer/architect to correct building type to permanently remove FSES.
SYSTEMIC CHANGES TO PREVENT FUTURE OCCURANCES:
Once plans are approved, Facility will request PA Department of Life Safety to conduct inspection to remove FSES.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):State only Deficiency.
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Name: MAIN/CENTRAL - Component: 01 - Tag: 0325

Based on observation and interview, it was determined the facility failed to install alcohol based hand sanitizer dispensers away from ignition sources, affecting one of three floors within the component.

Findings include:

1. Observation on October 9, 2019, at 11:31 AM revealed an alcohol based hand sanitizer dispenser was installed directly above an electrical receptacle, within the 1 Central Soiled-Linen Room, by the Unit Manager's Office.

Interview with the Maintenance Supervisor on October 9, 2019, at 11:31 AM confirmed the dispenser was above a receptacle.


 Plan of Correction - To be completed: 11/20/2019

CORRECTIVE ACTION FOR AREAS AFFECTED:
Alcohol based hand sanitizer dispenser was removed and relocated so that it is not directly above an electrical receptacle.
OTHER AREAS AFFECTED:
Administrator to educate Maintenance Director/designee on not installing an alcohol based hand sanitizer dispenser over an electrical receptacle.
SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Maintenance Director/Designee will conduct random weekly audits of facility x 4 weeks to ensure no alcohol based hand sanitizer dispensers are installed directly above an electrical receptacle.
MONITORING OF CORRECTIVE ACTION:
Audit outcomes will be reviewed by the Interdisciplinary Team at the center's monthly Quality Assurance meeting for compliance. Action plan will be developed as needed.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:State only Deficiency.
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/CENTRAL - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler heads to be unobstructed, and have a complete assembly, affecting two of three floors within the component.

Findings include:

1. Observation on October 9, 2019, at 11:08 AM revealed sprinkler heads, within the 2nd floor 2 Central Shower Room, were obstructed by a solid curtain, installed on the ceiling.

Interview with the Maintenance Supervisor on October 9, 2019, at 11:08 AM confirmed the curtain was solid, to the ceiling, and obstructed the flow of water from the sprinkler system.


2. Observation on October 9, 2019, at 11:20 AM revealed a sprinkler head, located in the 1st floor 1 Central Nourishment Room, lacked an escutcheon.

Interview with the Maintenance Supervisor on October 9, 2019, at 11:20 AM confirmed the lack of an escutcheon.


 Plan of Correction - To be completed: 11/20/2019

CORRECTIVE ACTION FOR AREAS AFFECTED:
Shower curtain was immediately removed and replaced by appropriate curtain. Escutcheon around the sprinkler head on the 1st floor 1 Central Nourishment room has been replaced.
OTHER AREAS AFFECTED:
Administrator to educate Maintenance Director/Designee on ensuring proper shower curtains are in place and that escutcheons are in place.
SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Maintenance Director or designee will conduct random weekly audits x 4 weeks to ensure that there are no solid curtains in shower rooms and that escutcheons are in place.
MONITORING OF CORRECTIVE ACTION:
Audit outcomes will be reviewed by the Interdisciplinary Team at the center's monthly Quality Assurance meeting for compliance. Action plan will be developed as needed.

NFPA 101 STANDARD Corridor - Doors:State only Deficiency.
Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. 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/CENTRAL - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain latching hardware of corridor doors, affecting one of three floors within the component.

Findings include:

1. Observation on October 9, 2019, at 11:11 AM revealed the door, to the 2nd floor 2 Central Resident Restroom, failed to positively latch within the frame.

Interview with the Maintenance Supervisor on October 9, 2019, at 11:11 AM confirmed the door did not positively latch.



 Plan of Correction - To be completed: 11/20/2019

CORRECTIVE ACTION FOR AREAS AFFECTED:
The 2nd floor 2 Central Resident Restroom door was repaired and now does positively latch within the frame.
SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Maintenance Director/Designee will conduct random weekly audits of resident restroom doors x4 weeks to ensure compliance.
MONITORING OF CORRECTIVE ACTION:
Audit outcomes will be reviewed by the Interdisciplinary Team at the center's monthly Quality Assurance meeting for compliance. Action plan will be developed as needed.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:State only Deficiency.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN/CENTRAL - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide at least two smoke compartments on every sleeping room floor, with greater than 30 residents, affecting two of three floors within the component.

Findings include:

1. Observation on October 9, 2019, between 10:00 AM and 1:00 PM revealed the 1st and 2nd floors lacked smoke barrier walls.

Interview with the Maintenance Supervisor on October 9, 2019, at 1:00 PM confirmed the lack of smoke barriers.



 Plan of Correction - To be completed: 11/20/2019

Facility has received Life Safety Floor plans from an Architect that verify all fire/smoke compartments are within the required Square feet and travel distances. Facility final FSES inspection from DSI in order to clear the current FSES that is in place.
Maintenance Director/Designee will conduct random weekly audits of all fire and smoke barrier walls to ensure compliance.
Audit outcomes will be reviewed by the Interdisciplinary Team at the center's monthly Quality Assurance meeting for compliance. Action plan will be developed as needed.

Initial comments:Name: NEW/SOUTH - Component: 02 - Tag: 0000


Facility ID #023902
Component 02
New/South Building

Based on a Relicensure Survey completed on October 9, 2019, it was determined that Brandywine Hall was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:State only Deficiency.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: NEW/SOUTH - Component: 02 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge protectors, affecting one of two floors within the component.

Findings include:

1. Observation on October 9, 2019, at 12:30 PM revealed a surge protector suspended by the flexible cord at the Nurses' Station.

Interview with the Maintenance Supervisor on October 9, 2019, at 12:30 PM confirmed the surge protector was suspended by electrical cord.



 Plan of Correction - To be completed: 11/20/2019

CORRECTIVE ACTION FOR AREAS AFFECTED:
The mobile surge protector at the 1 Central Nursing Station was moved to the floor so that it was no longer suspended by flexible cord.
OTHER AREAS AFFECTED:
Maintenance Director/Designee to educate staff that no mobile surge protectors may be suspended by flexible cord.
SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Maintenance Director/Designee will conduct random weekly audits of nursing stations x 4 weeks to ensure that there are no mobile surge protectors suspended by flexible cord.


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