Nursing Investigation Results -

Pennsylvania Department of Health
HUNTINGDON PARK REHAB CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HUNTINGDON PARK REHAB CENTER
Inspection Results For:

There are  34 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.
HUNTINGDON PARK REHAB 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 September 17, 2019, at Huntingdon Park Rehab Center, it was determined there was 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# 083402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 17, 2019, it was determined that Huntingdon Park Rehab 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 three-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.








 Plan of Correction:


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 the vertical opening enclosure in two instances affecting three of six smoke compartments.

Findings include:

1. Observation on September 17, 2019, revealed the following:

a) 11:48 a.m., there was a large penetration in the cement block wall above the elevator doors on the 2nd floor.
b) 12:34 p.m., there were two metal ceiling supports penetrating the cement block wall above the elevator doors on the ground floor.

Interview with the Facility Administrator and the Maintenance Supervisor on September 17, 2019, at 1:30 p.m., confirmed the penetrations in the vertical opening enclosure.





 Plan of Correction - To be completed: 10/30/2019

1. The facility immediately sealed penetrations to meet the requirements of fire code.
a) The cement block wall above 2nd floor elevator doors; was sealed with 3 M Fire Barrier Sealant 4 hr rated.
b) The cement block wall above 1st floor elevator doors; was sealed with 3 M Fire Barrier Sealant 4 hr rated.

2. The facility Maintenance Director and/or designee will perform routine safety rounds to observe for potential penetration concerns and repair as required.

3. The Maintenance Director will check for compliance with smoke barrier construction and penetrations via facility safety rounds and daily maintenance inspection rounds. These rounds are reported directly to the Administrator. Findings are reported by the Maintenance Director and/or designee monthly and/or quarterly to the facility Safety Committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 six smoke compartments.

Findings include:

Observation on September 17, 2019, at 11:59 a.m., revealed a missing sprinkler escutcheon in the first floor med room.

Interview with the Facility Administrator and the Maintenance Director on September 17, 2019, 1:30 p.m., confirmed the automatic sprinkler deficiency.




 Plan of Correction - To be completed: 10/30/2019

The missing sprinkler escutcheon in the first floor med room was replaced following the survey.

The Director of Maintenance will purchase additional escutcheons to have in stock in the event one becomes damaged or found to not be in place.
The Director of Maintenance will add a task into the TELS Work Order System to trigger an inspection of all sprinkler heads and escutcheons surrounding the sprinkler to be completed every 6 months to be completed by maintenance personnel.

Findings from the inspections will be reported to the Safety Committee. Any reports of non-compliance can then be reviewed to determine the action plan.

NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the corridor doors in one instance, for one of over 100 corridor doors tested.

Findings include:

Observation on September 17, 2019, at 12:30 p.m., revealed the door to the clean linen room on the ground floor was propped open with an unapproved hold open device, which would not allow the door to close and latch.

Interview with the Facility Administrator and Maintenance Director on September 17, 2019, at 1:30 p.m., confirmed the corridor door was propped open.






 Plan of Correction - To be completed: 10/30/2019

The door to the clean linen room on the ground floor was closed immediately.
The Clean Linen Room does not house hazardous chemicals, however, the door was propped open with an improper hold open device.

To prevent this from re-occurring the Director of Housekeeping was educated on door closure safety.

The Director of Housekeeping and Maintenance Director will educate all housekeeping, laundry and maintenance staff members on the proper procedure for door closure safety.

The Administrator will educate all Department Managers on the proper procedure for door closure safety in order to assist in prevention in other areas of the facility. Should any doors be found improperly propped open the department manager will report to the Safety Committee for review and a continuing action plan.

NFPA 101 STANDARD Electrical Systems - Other: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.
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 that the facility failed to maintain the electrical wiring in two instances, affecting two of six smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code. 19.5.1.1, NFPA 101.

Findings include:

1. Observation on September 17, 2019, revealed the following:

a) 11:38 a.m., 2nd floor bio-hazard room there was a missing electrical outlet, leaving an open electrical box with exposed wiring, by the sink;
b) 11:55 a.m., 1st floor bio-hazard room there was a missing electrical outlet leaving an open electrical box with exposed wiring, by the sink.

Interview with the Facility Administrator and the Maintenance Director on September 17, 2019, at 1:30 p.m., confirmed the missing electrical outlets and open electrical boxes with exposed wiring.







 Plan of Correction - To be completed: 10/30/2019

It was determined that the maintenance staff removed the outlets while repairing piping under the stainless steel cabinet in which the outlet was housed. The maintenance failed to replace the outlets.
The missing electrical outlet in the 2nd Floor Bio-Hazard Room has been replaced with a hospital grade GFI outlet box and cover.
The missing electrical outlet in the 1st Floor Bio-Hazard Room has been replaced with a hospital grade GFI outlet box and cover.

The facility Maintenance Director will perform routine safety rounds to include outlet monitoring. Results of the safety rounds will be reported to the Safety Committee.

The Maintenance Director and or designee will report findings of outlet compliance or non-compliance to the Quality Assurance Steering Committee. The Committee will determine plan of action based on findings.

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 Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0916

Based on observation and interview, it was determined the facility failed to maintain the remote alarm annunciator for the emergency generator, affecting the entire facility.

Findings include:

Observation on September 17, 2019, at 11:57 a.m., revealed the remote generator annunciator panel located on the 1st floor, showed four failure codes and indicated the generator was running when it was not.

Interview with the Facility Administrator and the Maintenance Director on September 17, 2019, at 1:30 p.m., confirmed the generator remote annunciator was not functioning properly.



 Plan of Correction - To be completed: 10/30/2019

The remote generator annunciator panel located on the 1st floor, showed four failure codes and indicated the generator was running when it was not. The Director of Maintenance met with the Engineering Director from the attached hospital whom operates the generator to inform him of the failure codes present. (Our facility receives all utilities, including back-up generator services from the attached hospital).

Next, he contacted the annunciator panel operating company (C.B.) to inform them of the failure codes present. The vendor's technician was able to instruct the maintenance Director in resetting the panel remotely. The panel was reset and no codes are present.

The Maintenance Director has implemented a monthly TELS Work Order to inspect the annunciator panel for potential errors. The maintenance staff will visually check the annunciator panel during facility rounds daily.
The Administrator will add this TELS Task to the monthly Safety Minutes as an item that needs to be reported to the committee to ensure compliance.


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