Pennsylvania Department of Health
MILLCREEK MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 17 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.


MILLCREEK MANOR - 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, it was determined that Millcreek Manor 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 document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on February 27, 2024, at 10:22 a.m., revealed the facility lacked an emergency preparedness plan that included an annual review date of policies and procedures.

Interview with the maintenance director on February 27, 2024, at 10:22 a.m., confirmed the emergency preparedness plan did not include the above element.

Plan of Correction - To be completed: 03/08/2024

1.) Emergency preparedness policy and procedures annual review has been added to the Emergency Preparedness binder.

2.) Administrator/Designee will ensure emergency preparedness plan includes the policies and procedures annual review and will be added to the Emergency Preparedness binder immediately upon completion.

3.) Emergency preparedness binder will be housed in Maintenance department with a copy in the Administrators office to ensure immediate access.

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

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

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on February 27, 2024, at 10:00 a.m., revealed the following deficiencies at the time of the survey:
A. (10:00 a.m.) An annual site-specific emergency management training/testing for all staff based on the facility's policies and procedures;
B. (10:00 a.m.) The table top drill provided was the same date and policy review as the annual full-scale exercise.

Interview with the maintenance director on February 27, 2024, at 10:00 a.m., confirmed the emergency preparedness plan did not include the above elements.

Plan of Correction - To be completed: 03/08/2024

1.) The Director of Maintenance will perform two site-specific emergency training/testing drills for all staff in the facility and will document accordingly.

2.) A table-top training exercise will be completed on a separate occasion from site specific drills.

3.) Documentation will be immediately placed in the Emergency Preparedness binder.

Initial comments:Name: MILLCREEK MANOR - Component: 02 - Tag: 0000

Facility ID #131102
Component 02
Millcreek Manor

Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2024, it was determined that Millcreek Manor 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 five-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

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.

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: MILLCREEK MANOR - Component: 02 - Tag: 0211

Based on observation and interview, the facility failed to meet egress requirements on one of five building levels.

Findings include:

Observation on February 27, 2024, at 9:22 a.m., revealed the first floor therapy area had an emergency exit blocked off by caution tape, wooden barriers, and temporary contruction material.

Interview with the maintenance director on February 27, 2024, at 9:22 a.m., confirmed the deficiency and attempted to clear the exit at the time of the survey.

Plan of Correction - To be completed: 03/08/2024

1.) 1st floor Therapy exit door was blocked with wooden barriers and caution tape due to construction next door the facility.

2.)A call to the construction foreman was made and immediate action was taken to remove all barriers and add gravel to level cement pad with surrounding areas.

3.)Maintenance Supervisor will monitor on his daily rounds and inform maintenance staff to do periodic checks to ensure the egress stays clear.

NFPA 101 STANDARD Emergency Lighting:

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: MILLCREEK MANOR - Component: 02 - Tag: 0291

Based on document review and interview, the facility failed to test and inspect the battery-operated emergency lighting for twelve of twelve months.

Findings include:

Document review on February 27, 2024, at 9:45 a.m., revealed the facility lacked testing documentation for a monthly 30-second test of the emergency lighting.

Interview with the administrator and maintenance director on February 27, at 9:45 a.m., confirmed the emergency lighting documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 03/08/2024

1.) Upon review of the monthly Generator documentation by the Maintenance Supervise, the 30 second test of the emergency lighting had been done for the twelve-month period but was not properly written on the documentation.

2.) On the Monthly Generator Test documentation, it was written as "Battery Lamp Test" and not "30 second emergency lighting test."

3.) Maintenance Supervisor will write up new documentation that states the correct verbiage for this monthly test and all monthly tests moving forward.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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: MILLCREEK MANOR - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain emergency generators for one of one emergency generator.

Findings include:

Document review on February 27, 2024, at 10:00 a.m., revealed the emergency generator testing reports did not include monthly battery electrolyte-specific gravity or conductance testing for five of twelve months from the previous year.

Interview with the administrator and maintenance director on February 27, at 10:00 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 03/08/2024

1.) Moving forward, the monthly battery electrolyte-specific gravity (conductance) test will be performed at the time of our monthly Generator Load Test.

2.) Maintenance Supervisors will create new documentation to reflect the test and in service the Maintenance Staff on the importance of this test on a monthly basis.

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