Nursing Investigation Results -

Pennsylvania Department of Health
FULTON COUNTY MEDICAL CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FULTON COUNTY MEDICAL CENTER
Inspection Results For:
There are 22 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


FULTON COUNTY MEDICAL CENTER - 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 June 16, 2022, at Fulton County Medical Center Long Term Care Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: FULTON COUNTY MEDICAL CENTER (SNF) - Component: 10 - Tag: 0000

Facility ID# 061902
Component 10
Long Term Care Building

Based on a Medicare/Medicaid Recertification Survey completed on June 16, 2022, it was determined that The Fulton County Medical Center 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 (000), unprotected noncombustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

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.

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: FULTON COUNTY MEDICAL CENTER (SNF) - Component: 10 - Tag: 0133
Based on observation and interview, it was determined the facility failed to maintain two-hour fire resistance occupancy separation walls, in two instances, affecting the entire facility.

Findings include:

1. Observation on June 16, 2022, revealed the following unsealed penetrations in the two-hour fire resistance rated occupancy separation barriers:

a) 11:12 a.m., an above ceiling inspection at the doors leading into the Shimer corridor, revealed there was a unsealed sprinkler pipe in the two-hour occupancy separation wall;
b) 11:20 a.m., an above ceiling inspection at the doors leading into the Overly corridor, revealed there were multiple unsealed wire penetrations, in the two-hour occupancy separation wall.

Interview with the Facility Administrator and Facility Staff on June 16, 2022, at 1:30 p.m., confirmed the unsealed penetrations in the two-hour fire resistive rated occupancy separation walls.

Plan of Correction - To be completed: 07/08/2022

The maintenance staff cleaned and removed debris from the penetration areas. For the smaller penetration areas, fire caulk was used to seal the area. For large gaps, 3M fire putty was used to seal the penetrations. This was completed on June 29, 2022 in both the Shimer and Overly nursing home units. These areas will be monitored by the maintenance staff upon annual fire door inspections.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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: FULTON COUNTY MEDICAL CENTER (SNF) - Component: 10 - Tag: 0353
Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in four instance, affecting the entire facility.

Findings include:

1. Review of documentation and interview on June 16, 2022, revealed the following required automatic sprinkler system testing documentation was missing:

a) 9:27 a.m. three quarterly sprinkler reports performed within the last 12 months;
b) 9:28 a.m., one annual sprinkler report performed within the last 12 months
c) 9:30 a.m., a five year sprinkler report performed within the last five years.

2. Observation on June 16, 2022, at 11:03 a.m., revealed the facility failed to maintain a smoke/heat resistive ceiling for the proper activation/operation of the automatic sprinkler system. There was an unsealed pipe penetration in the ceiling above the P tack unit, in the Overly janitor room.

Interview with the Facility Administrator and Facility Staff on June 16, 2022, at 1:30 p.m., confirmed that the above listed automatic sprinkler system documentation was not avaible at the time of the survey, the unsealed pipe penetration in the ceiling was also confirmed.

Plan of Correction - To be completed: 07/29/2022

The sprinkler system testing had been completed for September 2021, December 2021 and March 2022 and documentation was in-house but not located during the survey. Maintenance staff and nursing home administration was educated on the location of this information. In addition, a survey readiness binder is being developed where this information will kept and updated as system testing occurs. This binder will be completed by the maintenance manager, the maintenance secretary and nursing home administration by July 29, 2022.

The unsealed pipe penetration in the ceiling above the P tach unit in the Overly janitor closet was fire caulked on 6/29/2022. This was completed by the maintenance staff.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: FULTON COUNTY MEDICAL CENTER (SNF) - Component: 10 - Tag: 0918
Based on observation and interview, it was determined the facility failed to perform the required annual fuel quality testing of the emergency generator. Maintenance shall be in accordance with NFPA 110, 8.3.8

Findings include:

1 Observation on June 16, 2022, at 10:10 a.m., revealed the facility failed to perform the required annual fuel quality test of the emergency generator.

Based on documentation review and interview, it was determined the facility failed to maintain the automatic transfer switch, in one instance, affecting the entire facility. Testing shale be accordance with NFPA 110, 8.4.6.

Findings include:

2. Review of documentation on June 16, 2022, at 10:20 a.m., revealed the facility failed to perform the required monthly testing/function of the automatic transfer switch, in the last twelve months.

Interview with the Facility Administrator and Facility Staff on June 16, 2022, at 1:30 p.m., confirmed the required annual fuel quality test and monthly transfer switch testing, had not been performed in the last twelve months.

Plan of Correction - To be completed: 07/29/2022

1. Power Systems Electric, Inc. was on site at Fulton County Medical Center on 6/30/2022. During this visit, they pulled a fuel sample from the fuel tank. The sample will be sent to a lab for analysis. Power Systems will provide test results to the Fulton County Medical Center upon receipt of them. This is expected to take about 2 weeks. Fulton County Medical Center will schedule the fuel sample testing on an annual basis.

2. The generator supplying Fulton County Medical Center has an automated system which triggers the automatic transfer switch. The maintenance department has updated the current generator test documentation form to include a column indicating that staff will monitor and ensure that the transfer switch goes from the standard position to the alternate position and back to the standard position during the monthly test. This will be completed by members of the maintenance department on a monthly basis.

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