Pennsylvania Department of Health
JEFFERSON HILLS HEALTHCARE AND REHABILITATION CENTER
Building Inspection Results

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JEFFERSON HILLS HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  41 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.
JEFFERSON HILLS HEALTHCARE AND REHABILITATION 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 February 27, 2024, at Jefferson Hills Heathcare and Rehabilitation Center, 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# 100202
Component 01
Main Building-1933 Building

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, it was determined that Jefferson Hills Healthcare and Rehabilitation 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 two-story, Type III (200), unprotected ordinary structure, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.

Findings include:

1. Review of documentation on January 27, 2024, at 8:30 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection.

Interview with the Facility Administrator and Maintenance Director on January 27, 2024, at 8:30 a.m. confirmed the annual fire door assembly inspection documentation was not available at the time of the survey.


 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 documentation for required emergency generator maintenance and testing in three instances, affecting the entire facility.

Findings include:

1. Review of documentation on February 27, 2024, at 8:45 a.m., revealed the facility lacked documentation verifying that the following items were performed:

a) 8:30 a.m., the annual 90-minute load bank test;
b) 8:45 a.m., the triennial four-hour test;
c) 8:25 a.m., the annual fuel quality analysis.

Interview with the Facility Administrator and Maintenance Director on February 27, 2024, at 8:45 a.m., confirmed the required annual and triennial generator testing documentation was not available at the time of the survey.



 Plan of Correction:

No approved Plan of Correction is on file.
Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000

Facility ID# 100202
Component 02
1987, 1965 Buildings

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, it was determined that Jefferson Hills Healthcare and Rehabilitation 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 two-story, Type II (000), unprotected noncombustible building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.

Findings include:

1. Review of documentation on January 27, 2024, at 8:30 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection.

Interview with the Facility Administrator and Maintenance Director on January 27, 2024, at 8:30 a.m. confirmed the annual fire door assembly inspection documentation was not available at the time of the survey.


 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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: BUILDING 02 - Component: 02 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain documentation for required emergency generator maintenance and testing in three instances, affecting the entire facility.

Findings include:

1. Review of documentation on February 27, 2024, at 8:45 a.m., revealed the facility lacked documentation verifying that the following items were performed:

a) 8:30 a.m., the annual 90-minute load bank test;
b) 8:45 a.m., the triennial four-hour test;
c) 8:25 a.m., the annual fuel quality analysis.

Interview with the Facility Administrator and Maintenance Director on February 27, 2024, at 8:45 a.m., confirmed the required annual and triennial generator testing documentation was not available at the time of the survey.


 Plan of Correction:

No approved Plan of Correction is on file.
Initial comments:Name: THERAPY ADDITION - Component: 04 - Tag: 0000

Facility ID# 100202
Component 04
Physical Therapy

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, it was determined that Jefferson Hills Healthcare and Rehabilitation 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 V (111), protected wood frame structure, without a basement, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: THERAPY ADDITION - Component: 04 - Tag: 0761

Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.

Findings include:

1. Review of documentation on January 27, 2024, at 8:30 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection.

Interview with the Facility Administrator and Maintenance Director on January 27, 2024, at 8:30 a.m. confirmed the annual fire door assembly inspection documentation was not available at the time of the survey.



 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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: THERAPY ADDITION - Component: 04 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain documentation for required emergency generator maintenance and testing in three instances, affecting the entire facility.

Findings include:

1. Review of documentation on February 27, 2024, at 8:45 a.m., revealed the facility lacked documentation verifying that the following items were performed:

a) 8:30 a.m., the annual 90-minute load bank test;
b) 8:45 a.m., the triennial four-hour test;
c) 8:25 a.m., the annual fuel quality analysis.

Interview with the Facility Administrator and Maintenance Director on February 27, 2024, at 8:45 a.m., confirmed the required annual and triennial generator testing documentation was not available at the time of the survey.


 Plan of Correction:

No approved Plan of Correction is on file.

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