Pennsylvania Department of Health
QUALITY LIFE SERVICES - CHICORA
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
QUALITY LIFE SERVICES - CHICORA
Inspection Results For:

There are  45 surveys for this facility. Please select a date to view the survey results.

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QUALITY LIFE SERVICES - CHICORA - 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 23, 2024, it was determined that Quaity Life Services-Chicora 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 meet testing and training requirements for one of one emergency preparedness plan.

Findings include:

Document review on January 23, 2024, at 9:22 a.m., revealed the facility failed to provide annual all-employee emergency preparedness training that covered on-site policies and procedures.
Interview with the environmental services director on January 23, 2024, at 9:22 a.m., confirmed training documentation was unavailable at the time of the survey.





 Plan of Correction - To be completed: 03/13/2024

A. On 1/24/23 maintenance Director completed an all employee education on emergency preparedness training that included on-site policies and procedures.

B. Maintenance Director will review with all new hires on the emergency preparedness binder, which is to include location of binder and contents within the binder

This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending

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


Facility ID #032402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 23, 2024, it was determined that Quality Life Services-Chicora 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 one-story, Type III (211), protected, ordinary building, with a partial basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Discharge from Exits: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.
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, the facility failed to maintain exit discharge requirements at four of six exits.

Findings include:

Observation on January 23, 2024, between 9:45 a.m. and 11:15 a.m., revealed the following exit discharges were not maintained following a recent snowfall. Snow accumulation can affect wheelchair, walker, and/or bed mobility:

A. ( 9:45 a.m.) Settlers dining room exit;
B. ( 10:10 a.m.) Exit near room 408;
C. ( 10:15 a.m.) Exit near room 111;
D. ( 11:15 a.m.) Exit near 200 memory lane.

Interview with the director of environmental services on January 23, 2024, at 11:15 a.m., confirmed the above exit discharges were not maintained at the time of the survey.






 Plan of Correction - To be completed: 03/13/2024

A. Following exit discharges were
immediately cleared free of all snow;
a. Exit near room 408 on 1/23/24
b. Exit near room 111 on 1/23/24
c. Exit near 200 Memory Lane on 1/23/24
d. Exit near Settlers Dining room 1/23/24

B. All exits and discharge areas will be inspected daily for 4 weeks to ensure areas are maintained and clear of snow.
This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending

NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous room requirements in one of three oxygen rooms.

Findings include:

Observation on January 23, 2024, at 10:00 a.m., revealed the Miller oxygen room door failed to positively latch when tested.

Interview with the environmental services director on January 23, 2024, at 10:00 a.m., confirmed the oxygen door failed to positively latch.



 Plan of Correction - To be completed: 03/13/2024

A. Latch on Miller Hall Oxygen Room was immediately replaced on 1/24/24.

B. Facility will check all Oxygen Room Doors to ensure proper latching daily for 1 week. Then week for 4 weeks.
This plan will be shared with the next

QAPI meeting and to be reviewed for tracking and trending

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on observation, document review, and interview, the facility failed to maintain fire alarm system and maintenance requirements for two of two components.

Findings include:

1. Observation on January 23, 2024, at 11:20 a.m., revealed resident room 111 had a red cap placed over the smoke detector, possibly delaying the activation of the detector in the event of an emergency.

Interview with the environmental services director on January 23, 2024, at 11:20 a.m., confirmed the red cap on the smoke detector.

2. Document review on January 23, 2024, at 9:55 a.m., revealed the facility was unable to provide the following fire alarm system documentation:
A. (9:55 a.m.) Annual fire alarm system inspection report;
B. (9:55 a.m.) Semi-annual smoke detector sensitivity report.

Interview with the environmental services director on January 23, 2024, at 9:55 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.





 Plan of Correction - To be completed: 03/13/2024

A. Smoke detectors can be covered with a red cap to prevent damage (dust, paint, etc.) when working in room.

B. Red cap was immediately removed from smoke alarm.

C. All smoke alarms within facility will be checked daily for 4 weeks to ensure that no caps are on smoke detectors.
This plan will be shared with the next

QAPI meeting and to be reviewed for tracking and trending

A. Maintenance Director reached to Valley Security Systems on 1/31/24 to schedule annual fire alarm inspection. Inspection is scheduled for February 5, 2023

B. Penetrative maintenance schedule updated to include documentation of annual fire alarm inspection.

C. Maintenance Director reached Valley Security Systems was contacted on 1/31/24 and is scheduled to come in on February 5, 2023 and complete sensitivity test.

D. Preventative maintenance schedule updated to include semi-annual sensitivity test.

This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on document review and interview, the facility failed to maintain building subdivision space requirements for two of two components.

Findings include:

Document review on January 23, 2024, at 9:12 a.m., revealed the facility was unable to provide documentation for the four-year fire damper inspection report.

Interview with the environmental services director on January 23, 2024, at 9:12 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.




 Plan of Correction - To be completed: 03/13/2024

A. On January 31, 2024 Environmental Director made phone call to United Safety Services to schedule damper inspection report.

B. United Safety Services is scheduled to come in on 3/13/2024

C. Damper Inspection added to TELS to ensure timely completion

This plan will be shared with the next
QAPI meeting and to be reviewed for tracking and trending

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 meet fire door assembly maintenance and testing requirements for two of two components.

Findings include:

Observation on January 23, 2024, at 8:44 a.m., revealed the facility was unable to provide annual fire door inspection documentation.

Interview with the environmental services director on January 23, 2024, at 8:44 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.



 Plan of Correction - To be completed: 03/13/2024

A. Inspection of Fire Doors within Facility has been added to TELS to ensure annual inspection is completed timely

B. Maintenance Director or designee will audit all fire doors monthly x4 months.

C. Task will be added to TELS to ensure completion.

This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000


Facility ID #032402
Component 02
Building 02

Based on a Medicare/Medicaid Recertification Survey completed on January 23, 2024, it was determined that Quality Life Services-Chicora 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 one-story, Type II (111), protected, non-combustible building, with a partial basement, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0324

Based on document review and interview, the facility failed to meet inspection requirements for one of two semi-annual kitchen exhaust hood/duct cleaning inspections.

Findings include:

Document review on January 23, 2024, at 9:00 a.m., revealed the facility provided documentation for one kitchen hood cleaning (dated September 13, 2023), but failed to provide additional cleaning inspection documentation.

Interview with the environmental services director on January 23, 2024, at 9:00 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.



 Plan of Correction - To be completed: 03/13/2024

A. Most recent inspection of kitchen exhaust hood/duct was completed on 1/11/24.

B. Maintenance Director contacted United Safety Services on 1/31/24 and scheduled next inspection for the following date March 13, 2024 to ensure semi-annual inspection of kitchen exhaust hood/duct is meet per Life Safety Code K0761

C. Preventative maintenance schedule updated to include semi—annual kitchen exhaust hood/duct inspection

This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0345

Based on document review and interview, the facility failed to maintain fire alarm system requirements for two of two components.

Document review on January 23, 2024, at 9:55 a.m., revealed the facility was unable to provide the following fire alarm system documentation:
A. (9:55 a.m.) Annual fire alarm system inspection report;
B. (9:55 a.m.) Semi-annual smoke detector sensitivity report.

Interview with the environmental services director on January 23, 2024, at 9:55 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.



 Plan of Correction - To be completed: 03/13/2024

A. Maintenance Director reached to Valley Security Systems on 1/31/24 to schedule annual fire alarm inspection. Inspection is scheduled for February 5, 2023

B. Penetrative maintenance schedule updated to include documentation of annual fire alarm inspection.

C. Maintenance Director reached Valley Security Systems was contacted on 1/31/24 and is scheduled to come in on February 5, 2023 and complete sensitivity test.

D. Preventative maintenance schedule updated to include semi-annual sensitivity test.

This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0372

Based on document review and interview, the facility failed to maintain building subdivision space requirements for two of two components.

Findings include:

Document review on January 23, 2024, at 9:12 a.m., revealed the facility was unable to provide the four-year fire damper inspection report.

Interview with the environmental services director on January 23, 2024, at 9:12 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.



 Plan of Correction - To be completed: 03/13/2024

A. On January 31, 2024 Environmental Director made phone call to United Safety Services to schedule damper inspection report.

B. United Safety Services are scheduled to come in on 3/13/2024

C. Tasks will be added to TELS to ensure completion.


This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending

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: BUILDING 02 - Component: 02 - Tag: 0761

Based on document review and interview, the facility failed to meet maintenance and testing requirements for fire door assemblies for two of two components.

Findings include:

Observation on January 23, 2024, at 8:44 a.m., revealed the facility was unable to provide annual fire door inspection documentation.

Interview with the environmental services director on January 23, 2024, at 8:44 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.



 Plan of Correction - To be completed: 03/13/2024

A. Inspection of Fire Doors within Facility has been added to TELS to ensure annual inspection is completed timely

B. Maintenance Director or designee will audit all fire doors monthly x4 months

C. Tasks has been added to TELS to ensure completion

This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending

NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0911

Based on observation and interview, the facility failed to meet electrical system requirements for one of two components.

Findings include:

Observation on January 23, 2024, at 10:12 a.m., revealed an open breaker slot (panel K) in the basement, near the kitchen.

Reference: NFPA 70-408.7

Interview with the environmental services director on January 23, 2024, at 10:12 a.m., confirmed the open conductor slot.








 Plan of Correction - To be completed: 03/13/2024

A. Maintenance Director placed safety cap in breaker slot (panel K) on 1/30/24.

B. All panel boxes with facility will be inspected monthly for 4 month to ensure that there are no open slot with in the breaker box.

C. Preventative maintenance schedule updated to include documentation of all facility breaker boxes to check monthly.

This plan will be shared with the next QAPI meeting and to be reviewed for tracking and trending


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