Pennsylvania Department of Health
PAVILION AT BRMC, THE
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PAVILION AT BRMC, THE
Inspection Results For:

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PAVILION AT BRMC, THE - 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 January 18, 2024, it was determined that The Pavilion at BRMC had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing: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.
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to develop an emergency preparedness plan that included annual emergency preparedness plan staff training for one of one plan.

Findings include:

Document review on January 18, 2024, at 10:30 a.m., revealed the facility lacked documentation that all staff had underwent annual emergency preparedness training within the previous twelve months.

Interview with the maintenance supervisor on January 18, 2024, at 10:30 a.m., confirmed the facility lacked training documentation.




 Plan of Correction - To be completed: 02/16/2024

The Pavilion @ BRMC had an unscheduled power outage on 09/05/2023. The Incident Command was activated by J. Backhus, Plant & Facility Services Manager due to lack of proper functioning equipment during the power outage. EMA was contacted during the power outage which provided A/C for patients with breathing issues during the heat. Power was restored at 1855. Staff education will be completed by 2/14/2024 on the Pavilion's emergency operations plan and procedure. Staff participation will be documented by staff signing in-service sheet acknowledging understanding of the EOPP.
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID #024702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 18, 2024, it was determined that The Pavilion at BRMC 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 four-story, Type II (222), fire resistive building, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:This is a less serious (but not lowest level) 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 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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, the facility failed to properly document the testing, inspection, and repair of rated door assemblies, affecting four of four levels.

Findings include:

Document review on January 18, 2024, at 10:10 a.m., revealed the annual inspection for fire-rated door assemblies was not competed within the last year.

Interview with the maintenance supervisor on January 18, 2024, at 10:10 a.m., confirmed the annual inspection deficiency.






Based on document review and interview, the facility failed to meet door maintenance, inspection, and testing requirements for one of one facility.

Findings include:

Document review on January 18, 2024, at 12:10 p.m., revealed the facility lacked documentation for the annual fire door assembly inspection. The last documented inspection occurred in 2022.

Interview with the maintenance director on January 18, 2024, at 12:10 p.m., confirmed the documention was unavailable at the time of the survey.


 Plan of Correction - To be completed: 02/16/2024

A new fire door book on how to properly inspect and repair fire doors in accordance to NFPA standards has been created by and will be kept by the Plant Services Manager. Fire door inspections are being completed on 1/24/24 and findings will be kept in the new fire door log. Any areas of concern from inspections will be addressed immediately. Findings from the inspections will be discussed in QAPI.

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