Pennsylvania Department of Health
GERMANTOWN HOME
Building Inspection Results

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GERMANTOWN HOME
Inspection Results For:

There are  44 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.
GERMANTOWN HOME - 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 December 18, 2023, at Germantown Home, 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 #122702
Component 01
Health Care Building

Based on a Medicare/Medicaid Recertification Survey completed on December 18, 2023, it was determined that Germantown Home 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 four-story, Type II (222), fire resistive construction, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Exit Signage: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.
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on document review and interview, it was determined the facility failed to inspect exit signage, affecting the entire component.

Findings include:

Document review on December 18, 2023, at 8:45 a.m., revealed the facility could not provide documentation of monthly exit sign inspections.

Exit interview with the Administrator and the Maintenance Director on December 18, 2023, at 12:00 p.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 02/16/2024

1. The facility systematic change will be audit tool of exit signs will be used.

2.The corrective action will be monitored by completing audits weekly x4 for one month and monthly x2 and reviewed by Maintenance Director.
3. Findings of audit will be reported in QAPI for 3 months.
4. Corrective action will be in place by 2/16/2024.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire component.

Findings include:

Document review on December 18, 2023, at 8:45 a.m., revealed the facility could not provide documentation of a 2 year smoke detector sensitivity report.

Exit interview with the Administrator and the Maintenance Director on December 18, 2023, at 12:00 p.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 02/16/2024

1.Facility will maintain 2 -year smoke detector sensitivity report in facility. TELS system will be utilized to alert maintenance director of 2-year smoke detector sensitivity report due.
2. The corrective action will be monitored by Maintenance Director to ensure documentation of 2-year smoke detector sensitivity report is in facility. TELS system will be utilized to alert maintenance director of 2year report due.
3. Upcoming monthly maintenance inspections will be reported in QAPI for 3 months.
4. Corrective Action will be in place by 2/16/2024.


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 and inspect the sprinkler system, affecting the entire facility.

Findings include:

Document review on December 18, 2023, at 8:45 a.m., revealed the facility could not provide documentation of the weekly 30 minute run of the fire pump prior to June of 2023.

Exit interview with the Administrator and the Maintenance Director on December 18, 2023, at 12:00 p.m., confirmed the lack of documentation.




 Plan of Correction - To be completed: 02/16/2024

1. Facility will maintain consistent documentation of weekly 30 minute fire pump.
2. Maintenance Director/designee will place on weekly calendar for fire pump runs ongoing.
3. Fire pump runs will be reviewed in QAPI monthly x3.
4. Corrective action will be in place by 2/16/2024.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of smoke barriers, affecting one of four levels in the component.

Findings include:

Observation on December 18, 2023, at 11:15 a.m., revealed, on the fourth floor, an open penetration of the smoke barrier next to resident room 404 by MC cable.

Exit interview with the Administrator and the Maintenance Director on December 18, 2023, at 12:00 p.m., confirmed the open penetration.





 Plan of Correction - To be completed: 02/16/2024

1. Penetration was sealed around data wire with fire rated material using UL design No.U404 during survey.
2. Maintenance Director/designee will audit the 4th floor by double doors next to resident room 404 by MC cable weekly x4 for one month and monthly x2.
3. Findings will be reported in QAPI for 3 months.
4. Corrective action will be in place by 2/16/24.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu: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.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of Laundry Chutes, affecting one of four levels in the facility.

Findings include:

Observation on December 18, 2023, at 11:18 a.m., revealed, on the fourth floor, the door to the laundry chute failed to latch.

Exit interview with the Administrator and the Maintenance Director on December 18, 2023, at 12:00 p.m., confirmed the door failed to latch.





 Plan of Correction - To be completed: 02/16/2024

1. The laundry chute handle was immediately replaced on 4th floor with fire rated handle.
2. Maintenance Director/designee will audit the latching of laundry chute doors on all 3 units.
3. Findings will be reviewed in QAPI weekly x4 for one month and monthly x2.
4. Corrective action will be in place by 2/16/2024.


NFPA 101 STANDARD Electrical Systems - Receptacles: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 - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0912

Based on documentation review and interview it was determined the facility failed to ensure that electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire component.

Findings include:

Document review on December 18, 2023, at 8:45 a.m., revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Exit interview with the Administrator and the Maintenance Director on December 18, 2023, at 12:00 p.m., confirmed the facility could not provide documentation that the receptacles were tested.




 Plan of Correction - To be completed: 02/16/2024

A. Facility will maintain annual polarity report in facility & will add to TELS maintenance system to alert Maintenance Director/designee. Polarity test completed and in Life Safety binder.
B. Maintenance Director and maintenance team will be educated on record keeping of tests and results Maintenance Director will ensure polarity test is done yearly and documentation is in facility Life Safety binder.

C. Maintenance Director will report in QAPI polarity test completion with monthly reports of tests when due of upcoming months tests due and results in Life Safety binder.
D. Polarity Test was completed on survey date paperwork was misplaced, polarity test has been completed for corrective action date.
D. Corrective action will be in place by 2/16//2024.



NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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 document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting five of twelve reports.

Findings include:

Document review on December 18, 2023, at 8:45 a.m., revealed the facility could not provide documentation of the following tests:

a. Monthly testing of battery conductance after July of 2023;
b. 3 year, 4 hour load test.

Exit interview with the Administrator and the Maintenance Director on December 18, 2023, at 12:00 p.m., confirmed the lack of documentation.





 Plan of Correction - To be completed: 02/16/2024

A.
1. The Maintenance Director/designee will perform monthly conductance battery testing and will attach receipts to monthly generator reports.
2.The Maintenance Director will monitor monthly battery testing audits.
3. The corrective action will be reported in QAPI monthly x6.
4. Corrective action will be in place by 2/16/2024
B
1.Facility has had it's 4-hour Load test completed.
2. Facility will maintain the 3- year, 4-hour load test report in facility & will add to TELS maintenance system to alert Maintenance Director/designee.
3. The corrective action will be monitored through the TELS system alerting Maintenance Director of due inspection.
4. Upcoming monthly maintenance inspections will be reported in QAPI for 3-months.
5.Corrective action will be in place by 2/16/2024.



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