Pennsylvania Department of Health
 DELAWARE VALLEY VETERANS' HOME
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
DELAWARE VALLEY VETERANS' HOME
Inspection Results For:

There are  50 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.
DELAWARE VALLEY VETERANS' 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 February 20, 2024, at Delaware Valley Veterans' 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 - Component: 01 - Tag: 0000

Facility ID# 12720200
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 20, 2024, it was determined that Delaware Valley Veterans' 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 two-story, Type II (111), protected non-combustible construction, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211
Based on observation and interview, it was determined the facility failed to maintain means of egress free of obstructions to full use, affecting one of three levels.

Findings include:

1. Observation on February 20, 2024, at 10:55 am, revealed the exit door from the C-Wing stair tower required excessive force to open.

Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the excessive force to open the exit door.



 Plan of Correction - To be completed: 04/20/2024

Contractors have been contacted, a quote was generated, and the door and frame will be replaced.

Moving forward fire exit doors inspections will be done monthly for proper function.
The results of all audits will be reviewed at the Quality Assurance & Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/ interventions for ongoing compliance.




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 - Component: 01 - Tag: 0291
Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was tested at required intervals, affecting two of three levels.

Findings include:

1. Document review on February 20, 2024, at 9:00 am, revealed, documentation verifying an annual 90-minute test of the facility ' s battery back-up lighting was not available at time of survey.

Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the missing documentation.



 Plan of Correction - To be completed: 04/20/2024

All emergency lighting was tested on 2/21/2024 and will be tested semi annually going forward.

The results of all audits will be reviewed at the Quality Assurance & Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/ interventions for ongoing compliance.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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 - Component: 01 - Tag: 0345
Based on document review and interview, it was determined the facility failed to maintain fire alarm system components, affecting one of three levels.

Findings include:

1. Document review on February 20, 2024, at 9:00 am, revealed the March 2, 2023, Fire alarm inspection listed 1-80 duct detector as inaccessible due to remodel. Evidence of corrective action was not available at time of survey.

Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the deficiency.



 Plan of Correction - To be completed: 04/20/2024

The contractor has verified the duct detector is working correctly and documentation will be obtained.

The facility has labeled the location of duct detector access for future inspection.

Contractor contacted and documentation verifying the corrective action was completed will be obtained.

Moving forward documentation review will be completed quarterly to ensure corrective action information is available from the contractor with each inspection.

The results of all audits will be reviewed at the Quality Assurance & Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/ interventions for ongoing compliance.

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 - 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 February 20, 2024, at 9:00 am, revealed the September 7, 2023, annual sprinkler inspection report listed the following deficiencies, evidence of corrective action was not available at time of survey:

a. 5-year hydro due.
b. No hydraulic nameplate
c. ITC Kitchen did not terminate in smooth orifice.
d. ITC Basement housekeeping did not terminate in smooth orifice.
e. 1-1/4 test drain not connected to main drain.

Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the sprinkler system deficiencies.


2. Document review on February 20, 2024, at 9:00 am, revealed the December 5, 2023, quarterly sprinkler inspection report listed the following deficiency, evidence of corrective action was not available at time of survey:

a. Test & drain valve is plugged off at the sectional and is not piped out, so flow switch is unable to be tested with flowing water.

Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the sprinkler system deficiency.




 Plan of Correction - To be completed: 04/20/2024

The facilities service vendor has been contacted to obtain the necessary documentation to clear deficiencies that have already been completed.

And quotes for the modifications and repairs needed to clear the Hydro test and test drain plug deficiencies are being obtained.

The hydraulic name plate information has been supplied to an outside vendor and will be replaced by that outside contractor.

Moving forward documentation review will be completed semiannually to ensure corrective action information is available at time of inspection.

The results of all audits will be reviewed at the Quality Assurance & Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/ interventions for ongoing compliance.


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 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walll separations, affecting one of three levels.

Findings include:

1. Observation on February 20, 2024, at 11:15 am, revealed above the doors separating memory care/skilled, an approximately 8 x 12-inch piece of drywall was missing from the rated wall.

Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the missing drywall.







 Plan of Correction - To be completed: 04/20/2024

The missing layer of sheetrock was replaced on 2/21/2024.

All similar areas will be inspected monthly for penetrations and the facilities above the ceiling permit procedure will be ongoing.

The results of all audits will be reviewed at the Quality Assurance & Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/ interventions for ongoing compliance.

NFPA 101 STANDARD Fire Drills: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.
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 - Component: 01 - Tag: 0712

Based on observation and interview, it was determined the facility failed to ensure fire drills were conducted at unexpected times, in four of twelve quarters within this facility.

Findings include:

1. Document review on February 20, 2024, at 9:00 am, revealed the third shift fire drills were all conducted in the 11:00 pm hour.

Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the above listed fire drills were not held at unexpected times.




 Plan of Correction - To be completed: 04/20/2024

Moving forward the facility will conduct fire drills no less than two hours from the time of the previous drills for any given shift

The fire drills will be audited monthly for 6 months to ensure drills are conducted at unexpected times without any patterns.

The results of all audits will be reviewed at the Quality Assurance & Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/ interventions for ongoing compliance.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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 Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920
Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting two of three levels.

Findings include:

1. Observations on February 20, 2024, revealed the following electrical deficiencies:

a. 10:30 am. 1st floor Physical Therapy, microwave into surge protector.
b. 11:15 am, basement pharmacy, extension cord powering a microwave.

Exit interview with the Administrator and Maintenance Director on February 20, 2024, at 12:00 pm, confirmed the unauthorized electrical devices.



 Plan of Correction - To be completed: 04/20/2024

Extension cords and surge protectors were immediately removed, and appliances were plugged directly into an outlet as per code.

Weekly audits will be conducted for 6 weeks to ensure compliance with code.

The results of all audits will be reviewed at the Quality Assurance & Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/ interventions for ongoing compliance.

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