Pennsylvania Department of Health
EMBASSY OF HUNTINGDON PARK
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EMBASSY OF HUNTINGDON PARK - 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 April 14, 2025, it was determined that Embassy of Huntingdon had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

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(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to review and update their emergency plan at least annually.

Findings include:

1. Interview and documentation review on April 14, 2025, at 9:00 a.m., revealed the Emergency Preparedness Plan was not updated in over 12 months.

Interview with the Facility Administrator and Maintenance Director on April 14, 2025, at 9:00 a.m., confirmed the EP plan was not reviewed and updated at least annually.

Plan of Correction - To be completed: 05/13/2025

1) The Regional Maintenance Director and/or designee will educate facilities maintenance staff on requirements for long-term care facility requirements to develop and maintain emergency preparedness plan and plan must be reviewed and updated at least annually.
Maintenance Director and/or designee will update the facility emergency preparedness plan to ensure that it meets requirements and will audit plan to ensure that it is updated with any new changes needed and at least yearly.
2) Results will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006
Based on document review and interview it was determined that the facility failed to provide a written Emergency Preparedness Plan that includes a facility-based and community-based risk assessment.

Findings include:

1. Interview and documentation review on April 14, 2025, at 9:50 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes a facility-based and community-based risk assessment, utilizing an all-hazards approach.

Interview with the Facility Administrator and the Maintenance Director on April 14, 2025, at 9:50 a.m., confirmed the facility Emergency Preparedness Plan lacked a facility-based and community-based risk assessment.

Plan of Correction - To be completed: 05/13/2025

1) The Regional Maintenance Director and/or designee will educate the facilities maintenance staff on requirements for Emergency Preparedness plan that includes a facility-based and community-based risk assessment. Plan is to be reviewed and updated at least annually.
Maintenance Director and/or designee will update the facility emergency preparedness plan to ensure that it meets requirements and will audit plan yearly and as needed to ensure that it is updated with any new changes needed.
2) Results will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.
Date certain:

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 April 14-15, 2025, it was determined that Embassy of Huntingdon 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 Fire Alarm System - Testing and Maintenance:

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 documentation review and interview, it was determined the facility failed to maintain the fire alarm system, in one instance, affecting the entire facility

Findings Include:

1. Review of documentation on April 14, 2025, at 9:15 a.m., revealed the the facility lacked documentation for the semi-annual visual fire alarm inspection.

Interview with the Facility Administrator and Maintenance Director on April 14, 2025 at 9:15 a.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 05/13/2025

1) The Regional Maintenance Director and/or designee will educate the facilities maintenance staff on requirements for providing documentation for semi-annual visual fire alarm inspection.
Maintenance and/or designee will audit semi-annual visual fire alarm inspection to ensure compliance requirements.
Semi-annual visual fire alarm inspection completed on: 4.21.2025
2) Results will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

NFPA 101 STANDARD Fire Drills:

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 perform two of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on April 14, 2025, at 8:30 a.m., revealed the facility lacked documentation for a third shift fire drill for the first quarter, and a first shift fire drill for the second quarter.

Interview with the Facility Administrator and Maintenance Director on April 14, 2025, at 8:30 a.m., confirmed the facility lacked documentation for the fire drills between January and June in 2024.

Plan of Correction - To be completed: 05/13/2025

1) The Regional Maintenance Director and/or designee will educate the facilities maintenance staff on requirements for quarterly fire drills on each shift
Maintenance and/or designee will audit monthly fire drills (date and time) to ensure that facility is following fire drill requirements
2) Results will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

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 documentation review and interview, it was determined the facility failed to maintain electrical receptacles in patient sleeping areas, affecting the entire facility.

Findings include:

1. Documentation review on April 14, 2025, at 9:35 a.m., revealed the facility lacked documentation for an annual tension and continuity test of non-hospital grade electrical receptacles in the patient sleeping rooms of the facility.

Interview with the Facility Administrator and Maintenance Director on April 14 , 2025, at 9:35 a.m., confirmed the facility lacked documentation for an annual test of non-hospital grade electrical receptacles in patient sleeping areas, performed within the last 12 months.

Plan of Correction - To be completed: 05/13/2025

1) The Regional Maintenance Director and/or designee will educate the facility maintenance staff on the requirements for maintaining electrical receptacles in patient sleeping areas.
Maintenance Director and/or designee will audit yearly electrical receptacles testing in patient sleeping areas yearly.
Electrical Receptacle testing completed on: 5/5/2025
2) Results of the audits will be reported to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after initial audits are reported to ensure that the deficiency is corrected.

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