Pennsylvania Department of Health
QUALITY LIFE SERVICES - HENRY CLAY
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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QUALITY LIFE SERVICES - HENRY CLAY - 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 August 6, 2024, at Quality Life Services Henry Clay it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID # 060602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 6, 2024, it was determined that Quality Life Services Henry Clay was not in compliance with the following requirements of the Life Safety Code for an existing healthcare 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 (000), unprotected noncombustible building, without a basement that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained, and operated to safely and efficiently render the services offered.

Based on observation and interview, it was determined the facility failed to obtain approval from the Division of Safety Inspection Plan Review Department, prior to conducting rehabilitation work, in one instance, affecting the entire facility.

Findings include:

1. Observation on August 6, 2024, at 9:30 a.m., revealed that demolition work had been done to separate the long-term care occupancy from the former personal care occupancy. There were no state-approved plans on-site.

Interview with the Facility Administrator and Maintenance Director on August 6, 2024, at 1:15 p.m., confirmed that plan review had not been contacted prior to beginning the rehabilitation project.

Plan of Correction - To be completed: 09/12/2024

Corporate office has requested user password info and will be submitting the plan for the separation of the former PC building and the skilled nursing facility.

NFPA 101 STANDARD Vertical Openings - Enclosure:

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.

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in one instance, affecting two of four smoke compartments.

Findings include:

1. Observation on August 6, 2024, at 11:18 a.m., revealed the elevator shaft wall was not sealed to the deck above the ceiling, at the first-floor elevator doors.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on August 6, 2024, at 1:15 p.m., confirmed the listed vertical opening enclosure deficiency.

Plan of Correction - To be completed: 09/12/2024

The unsealed elevator shaft was sealed with a UL approved through penetration product.

An audit was formed with all areas of potential for penetration. This audit will be completed monthly. Any penetrations found during the monthly audit they will be sealed with a UL approved through penetration product.

All audit's will become a part of the monthly QAPI review process.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of four smoke compartments.

Findings include:

Observation on August 6, 2024, at 11:20 a.m., revealed the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were unsealed pipe penetrations in the ceiling of the first-floor housekeeping storage room, above the water heater.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on August 6, 2024, at 1:15 p.m., confirmed the listed automatic sprinkler system deficiency.

Plan of Correction - To be completed: 09/12/2024

The unsealed penetrations in the Housekeeping room was sealed with a UL approved through penetration product.

Maintenance will use a new audit form with any area's with potential for a penetration monthly. Any area's of penetration found will be sealed at that time with a UL approved penetration product.

All audits will be reviewed at monthly QAPI meetings.

NFPA 101 STANDARD Fire Drills:

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.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to meet the requirements for fire drills to be held at unexpected times and varying conditions, for eight of 12 fire drills performed over the past four quarters, affecting the entire facility.

Findings include:

1. Review of documentation on August 6, 2024, at 9:45 a.m., revealed fire drills for the past four quarters for the first shift were all performed within a 45-minute time frame (1:37 p.m. to 2:22 p.m.), and fire drills for the past four quarters for the third shift were all performed within a 19-minute time frame (6:04 a.m. to 6:23 a.m.).

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on August 6, 2024, at 1:15 p.m., confirmed the listed fire drill deficiency.

Plan of Correction - To be completed: 09/12/2024

The maintenance staff received education on the proper procedure for completing fire drills on rotating shifts and times.

Fire drill logs will be reviewed at monthly QAPI meetings to assure that all drills are completed on all shifts with various times of the shift.

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