Pennsylvania Department of Health
 COMPLETE CARE AT HARSTON HALL LLC
Building Inspection Results

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COMPLETE CARE AT HARSTON HALL LLC
Inspection Results For:

There are  40 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.
COMPLETE CARE AT HARSTON HALL LLC - 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 26, 2024, at Complete Care At Harston Hall, Llc, 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# 080702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 26, 2024, it was determined that Complete Care at Harston Hall, LLC was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 three-story, Type II (222), fire resistive building, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to properly configure the headroom of exit stairways, affecting one of three exit stairways.

Findings include:

Observation on June 26, 2024, at 11:30 a.m., revealed , on the second floor, the North exit stairway, exit discharge landing provides only seventy-two inches of headroom clearance.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the headroom measurement was less than the required eighty inches.




 Plan of Correction - To be completed: 08/12/2024

Facility requests that an FSES be conducted by the Pennsylvania Department of Health to update current FSES relevant to the headroom of the North stair tower that measured six feet, zero inches from stair tread to overhead obstruction at the second floor exit discharge landing.
NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain its emergency lighting, affecting one of three floors.

Findings include:

Document review on June 26, 2024, at 9:30 a.m., revealed the facility lacked documentation showing annual 90-minute testing of battery back-up lighting.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 08/25/2024

Maintenance department completed required 90 min testing of battery backup lighting on 06/28/2024.
Maintenance will conduct annual testing and document. Documentation to be stored in maintenance and administrators' office.
Annual testing will be reported to QAPI.

NFPA 101 STANDARD Cooking Facilities: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was maintained, affecting one of three floors.

Findings include:

Document review on June 26, 2024, at 9:30 a.m., revealed the May 29, 2024, Kitchen suppression inspection report listed the following deficiencies, which remained uncorrected at time of survey:

a. A burst disc union needs to be installed on the discharge pipe per manufacturer (02/01/24).
b. Both cylinders are due for hydro testing.
c. Class K fire extinguisher is due for hydro testing.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the kitchen suppression deficiencies.




 Plan of Correction - To be completed: 08/25/2024

Tilley Fire Services have provided a quote to complete the Burst union and extinguisher replacement and testing.
Service will be scheduled within the next 60 days.
Maintenance will inspect kitchen fire suppression and extinguishers monthly to assure expiration dates have not been passed and hydro testing is up to date.
Log will be maintained in the maintenance office.
Results will be reported to QAPI.

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 and interview, it was determined the facility failed to maintain the fire alarm system, affecting the entire facility.

Findings include:

Observation on June 26, 2024, at 9:30 a.m., revealed the January 2024, fire alarm inspection report listed the following deficiencies, which remained uncorrected at time of survey:

a. The sounders in the smoke/sounders in multiple second floor and third floor rooms did not function at the time of the annual inspection 02/01/23 and 01/30/24 and need to be repaired or replaced.
b. The tampers in the pit did not report to the fire alarm control panel at the time of inspection 08/22/23 through 01/30/24 and need to be repaired or replaced.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the fire alarm deficiencies.




 Plan of Correction - To be completed: 08/25/2024

Tilley fire services have provided quotations for the repairs/replacement of the sounders.
Tilley fire services has provided a quotation for repair/replacement of the tampers in the pit.
Service will be scheduled within the next 60 days.
Annual inspections will be presented at QAPI.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Document review on June 26, 2024, at 9:30 a.m., revealed the May 2024, annual sprinkler inspection report listed the following deficiencies, evidence of corrective action was not available at time of survey:

a. Several sprinklers were observed to be too high at time of inspection 05/02/23 thru 05/29/24 and need to be adjusted.
b. The tampers in the pit did not function at time of inspection 05/02/23 thru 01/30/24 and need to be repaired or replaced (Were NOT tested on 5/29/24 due to excessive water in the pit).
c. There were two troubles on panel upon arrival and departure 5/29/2024.
d. The last inspection date for the FDC Hydro test is unknown and needs to be tested.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 .p.m, confirmed the sprinkler system deficiencies.

2. Observation on June 26, 2024, at 11:15 a.m., revealed , on the first floor, the sprinkler riser room lacked spare sprinklers and wrench.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the missing items.




 Plan of Correction - To be completed: 08/25/2024

1.
a) Tilley fire services has provided a quotation for the adjustment of the sprinkler height.
Service to be completed within 60 days.
b) Tilley fire services has provided a quotation for repair/replacement of the tampers in the pit.
Service will be scheduled within the next 60 days.
c) Troubles on the panel have been corrected.
d) HDRO testing will be completed within 60 days.
2) Spare sprinkler heads and wrenches have been placed in the riser room. Monthly audits will be conducted and results recorded in maintenance logs.


Annual inspections will be presented at QAPI.



NFPA 101 STANDARD Utilities - Gas and Electric: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.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of three levels.

Findings include:

Observation on June 26, 2024, at 11:45 a.m., revealed, on the third floor, in Nurses Station med room, a- non-GFCI outlets located within 6 feet of a sink. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6 ft of the outside edge of the sink.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the unprotected outlet.




 Plan of Correction - To be completed: 08/25/2024

Maintenance installed a GFCI outlet on 07/01/2024.
Maintenance canvased the entire building to determine if any other receptacles needed replacement and replaced as needed.
Results will be reported to QAPI.

NFPA 101 STANDARD HVAC: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.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting the entire facility.

Findings include:

Document review on June 26, 2024, at 9:30 a.m., revealed the facility lacked documentation indicating four-year exercise of the fire/smoke dampers was performed.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 08/25/2024

Tilley Fire Services have been scheduled to perform the damper testing, and exercise.
Service will occur in the next 60 days.
Results will be recorded and maintained in the Maintenance office.
Testing will be scheduled in TELS
Results will be reported to QAPI.

NFPA 101 STANDARD Smoking Regulations: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.
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741

Based on observation and interview, it was determined the facility failed to maintain smoking areas outside the facility, affecting one of three levels.

Findings include:

Observation on June 26, 2024, at 9:00 a.m., revealed residents smoking directly outside the building front entrance. This is a nonsmoking facility.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the employees smoking.




 Plan of Correction - To be completed: 08/25/2024

Facility is a nonsmoking facility. In an effort to accommodate non-compliant residents and to prevent accidents and incidents the facility has developed smoking rules and regulations. Residents who agree to this attachment are current residents of this facility, Harston Hall is not admitting any NEW smokers to the facility.
This includes smoking times, smoking assessments and safety equipment

NFPA 101 STANDARD Electrical Systems - Other: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of three levels.

Findings include:

Observation on June 26, 2024, at 11:20 a.m., revealed a junction box missing its protective cover- on the first floor, by Nursing office, above suspended ceiling.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the exposed wiring.




 Plan of Correction - To be completed: 08/25/2024

Maintenance installed the junction box cover on 07/01/2024.
Maintenance canvased the entire building to assure that all visible junction boxes are covered as required.
Results reported to QAPI.

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested at patient bed locations, affecting one of three floors.

Findings include:

Document review on June 26, 2024, at 9:30 a.m., revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested as required for non-hospital grade receptacles at intervals not exceeding 12 months. Receptacle testing should include the following:

a. visual inspection of physical integrity.
b. correct polarity of the hot and neutral connections.
c. retention force of the grounding blade (except locking-type receptacles) shall not be less than 4 oz.

*The facility failed to record the (b) polarity of the hot and neutral connections portion of receptacle testing.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed testing of electrical receptacles was incomplete.




 Plan of Correction - To be completed: 08/25/2024

Testing of all resident rooms, including visual inspection, correct polarity and retention force of the grounding blade, was completed and documented on 07/03/2024, by maintenance personnel.
No issues were found at the time of testing.
The results will be kept in the maintenance office.
Annual testing will be scheduled in TELS. And will not exceed 12 months

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting one emergency generator.

Findings Include:

Document review on June 26, 2024, at 9:30 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items:

a. weekly battery voltage.
b. monthly battery conductance.
c. annual 90-minute load bank.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 08/25/2024

a) Maintenance department conducted a battery voltage test upon notification of deficiency. No concerns noted.
Weekly voltage tests are being conducted with results recorded in Maintenace log.
b) Monthly battery test was conducted immediately upon notification of deficiency.
Monthly test will be conducted by maintenance and results recorded in maintenance log.
c) Annual 90-minute test was conducted by POWERHOUSE GENERATOR SERVICE, on 07/16/2024.
generator load testing will be scheduled annually by Maintencence department.
All results will be reported to QAPI.
NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of three levels.

Findings include:

Observation on June 26, 2024, at 11:00 a.m., revealed 2- unsecured oxygen cylinders in the oxygen storage room, on the first floor.

Exit Interview with the Administrator and Maintenance Director on June 26, 2024, at 12:40 p.m., confirmed the unsecured oxygen cylinders.




 Plan of Correction - To be completed: 08/25/2024

Oxygen tanks were secured immediately upon identification.
The entire facility was canvased for unsecured O2 tanks, none found.
Facility nursing and maintenance employees were inserviced in correct O2 storage process.
Maintenance Director/designee will audit facility weekly x 4 weeks and monthly x 2 months for compliance.
Results will be reported to QAPI.


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