Nursing Investigation Results -

Pennsylvania Department of Health
SAUNDERS HOUSE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SAUNDERS HOUSE
Inspection Results For:

There are  30 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.
SAUNDERS HOUSE - 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 September 23, 2019, it was determined that Saunders House was not in compliance with the requirements of 42 CFR 483.73.




 Plan of Correction:


483.73(d)(2) REQUIREMENT EP Testing Requirements: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.
(2) Testing. The [facility, except for LTC facilities, RNHCIs and OPOs] must conduct exercises to test the emergency plan at least annually. The [facility, except for RNHCIs and OPOs] must do all of the following:

*[For LTC Facilities at 483.73(d):] (2) Testing. The LTC facility must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The LTC facility must do all of the following:]

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based.
(B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For RNHCIs at 403.748 and OPOs at 486.360] (d)(2) Testing. The [RNHCI and OPO] must conduct exercises to test the emergency plan. The [RNHCI and OPO] must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the [RNHCI's and OPO's] response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, it was determined the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan, affecting the entire facility.

Findings include:

1. Review of documentation on September 23, 2019, at 8:15 am, revealed the facility failed to conduct the required annual-full scale exercise and additional exercise to test the emergency preparedness plan within the previous 12 months.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the documentation was not available.




 Plan of Correction - To be completed: 11/02/2019

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for the purposes of general liability, professional malpractice or any other court proceeding.
The facility is participating in a full scale exercise the week of October 28, 2019. This is the first full scale community drill that was available to us to participate.
We are active members of the Pennsylvania Regional Health Care Coalition and participate in the monthly meetings. We will work with them to ensure that we complete the required drills on an annual basis.
On November 1st a tabletop drill will be completed.
The completion of these drills will be reported at the QA meeting for their input and recommendations.
The Administrator is responsible to ensure that this is done.

483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power: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.
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

483.73(e), 485.625(e)
(e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

482.15(e)(1), 483.73(e)(1), 485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), 483.73(e)(2), 485.625(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), 483.73(e)(3), 485.625(e)(3)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at 482.15(h), LTC at 483.73(g), and CAHs 485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.
Observations:
Name: - Component: -- - Tag: 0041

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness Plan to include a plan to ensure the emergency generator provides continuous power during an emergency, affecting the entire facility.

Findings include:

1. Document review on September 23, 2019, at 8:15 am, revealed the facility's Emergency Preparedness plan lacked a written plan and written agreements or contracts with a secondary fuel supplier for the facility's emergency generator in the event the primary fuel supplier is unavailable during an emergency.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the documentation was not available.





 Plan of Correction - To be completed: 11/02/2019

The oil tank is kept full and will allow us to run the emergency generator for over 4 days.
We are active members of the Pennsylvania Regional Health Care Coalition and participate in the monthly meetings. We would work with this coalition to get more fuel should we need to run our generator for more than 4 days. We will also work to try to get a secondary fuel supplier to give us a letter stating that they will supply oil should we need to run the emergency generator for more than 4 days.
The ability to get the letters will be reported at the QA meeting for their input and recommendations.
The Director of Maintenance is responsible to ensure that this is done.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 190402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 23, 2019, it was determined that Saunders House 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 III (211), protected ordinary construction, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility.

Findings include:

1. Observation, documentation review and interview on September 23, 2019, at 8:15 am, revealed the facility's structure exceeds the maximum allowable story height for an existing health care occupancy. The building is a fully sprinklered, four-story Type III (211), protected ordinary construction.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the facility exceeds the maximum allowable story height.


2. Observations made on September 23, 2019, between 11:20 am and 1:42 pm, revealed unsealed penetrations in rated suspended ceiling tiles, and missing rated suspended ceiling tiles in the following locations:

a. 11:20 am, inside the 1st floor main kitchen boiler room, missing ceiling tile;
b. 11:45 am, inside the 1st floor main kitchen, above the wall mounted fire suppression system chemical tank, missing ceiling tile;
c. 1:20 pm, inside the 4th floor electrical storage room within the nurse's station area, gap around a sprinkler;
d. 1:42 pm, inside the 3rd floor therapeutic recreation storage room, multiple unsealed pipe penetrations in the rated suspended ceiling assembly.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the missing and unsealed penetrations in rated suspended ceiling tiles in the above named locations.


3. Observation made on September 23, 2019 at 1:40 pm, revealed inside the 3rd floor electrical room within the nurses station area, there was a gap in a rated suspended ceiling tile that was sealed with an unknown expanding spray foam.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the gap was sealed with an unknown spray foam.






 Plan of Correction - To be completed: 11/02/2019

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for the purposes of general liability, professional malpractice or any other court proceeding.
The facility worked with an outside consultant to complete an FSES to cover this deficiency and the FSES was submitted to the Department of Health.
The Administrator is responsible for monitoring this as a part of the QA committee and will report Life Safety requirements and plan of correction to the Committee.
Kitchen missing ceiling tiles, 4th floor electrical storage gap around sprinkler head, 3rd floor TR storage room multiple unsealed pipe penetrations, 3rd floor electrical room at nsg station gap filled with spray foam (not rated)
The ceiling tile in the kitchen main boiler room and above the fire suppression system were replaced. The gap around the sprinkler head was filled and the pipe penetrations on the 3rd floor were sealed using UL design W-L-3195 fire penetration system.
Random audits for missing ceiling tiles and gaps will be conducted monthly times three and reported at the QA meeting monthly times three for their review and recommendations.
The Director of Maintenance is responsible for this.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of exit stair tower enclosures, affecting 2 of 3 stair tower enclosures within the facility.

Findings include:

1. Observations made on September 23, 2019, between 1:15 pm and 1:55 pm, revealed unsealed penetrations in stair tower enclosures in the following locations:

a. 1:15 pm, 4th floor, an unsealed penetration around data wires, above the stair tower door across from resident room 401;
b. 1:55 pm, 2nd floor, two unsealed holes in the stair tower wall, near the deck above the stair tower door near resident room 202.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the unsealed penetrations in the above named locations.


2. Observation made on September 23, 2019, at 1:30 pm, revealed the 3rd floor stair tower door near resident room 329 was missing its rating label.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the rating label was missing.





 Plan of Correction - To be completed: 11/02/2019

The penetrations in the firewall was sealed using UL design C-AJ-3223 fire penetration system.
Random audits will be performed for three months to ensure that there are no penetrations and reported at the Quality Assurance meeting for their input and recommendations.
A new door was ordered and when it arrives, it will be installed.
Random audits of doors will be done monthly times three and the results reported to the QA committee for their review and recommendations.
The Director of Maintenance is responsible for this.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were accessible, affecting 1 of 12 smoke zones within the facility.

Findings include:

1. Observation made on September 23, 2019, at 11:37 am, revealed the K-type portable fire extinguisher inside the 1st floor main kitchen was blocked by a cart stored in front of it.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the extinguisher was blocked.





 Plan of Correction - To be completed: 11/02/2019

The fire extinguisher was to a location that will not be blocked by a cart.
Random audits will be done monthly time three to check placement to make sure it is not blocked. The results of the audits will be presented to the QA committee for their input and recommendations.
The Director of Dining Services is responsible for this.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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 observation and interview, it was determined the facility failed to ensure sprinklers were free of debris, affecting of levels 1 of 4 levels within the facility.

1. Observations made on September 23, 2019, between 11:14 am and 11:34 am, revealed sprinklers with debris on them, in the following locations:

a. 11:14 am, 1st floor clothes dryer room, multiple sprinklers behind and in front of the dryers;
b. 11:30 am, 1st floor, multiple sprinklers inside the washing machine room;
c. 11:34 am, 1st floor, multiple sprinklers throughout the main kitchen.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the sprinklers with debris, in the above named locations.







 Plan of Correction - To be completed: 11/02/2019

The sprinkler heads were immediately cleaned.
Random audits of sprinkler heads will be performed for three months to ensure that they are clean. The results of the audits will be reported at the QA meeting monthly times three for their input and recommendations.
The Director of Maintenance is responsible for this.

NFPA 101 STANDARD Corridor - Doors: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.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors positively latched into their frame, affecting 1 of 12 smoke zones within the facility.

Findings include:

1. Observation on September 23, 2019, at 1:35 pm, revealed on the 3rd floor, the door to resident room 317 failed to positively latch when tested.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the door failed to latch.





 Plan of Correction - To be completed: 11/02/2019

The latch on the door to room 317 was repaired
Random audits of the doors will be completed monthly times three
Results of the audits will be reported at the QA meetings monthly times three
The Director of Maintenance is responsible for this.

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 smoke barrier walls were free of unsealed penetrations, affecting 2 of 12 smoke zones within the facility.

Findings include:

1. Observation made on September 23, 2019, at 12:03 pm, revealed on the 1st floor, there were unsealed wall penetrations around orange and white flex pipes, above the smoke barrier double doors, near resident room 101.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019, at 2:35 pm, confirmed the unsealed flex pipe penetrations.






 Plan of Correction - To be completed: 11/02/2019

The penetration in the firewall was sealed using UL design W-L-3195 fire penetration system.
Random audits will be performed for three months to ensure that there are no penetrations and reported at the Quality Assurance meeting monthly times three for their review and recommendations.
The Director of Maintenance is responsible for this.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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 - 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 ensure the emergency generator was tested as required, affecting the entire facility.

Findings include:

1. Document review on September 23, 2019, at 8:15 am, revealed the facility could not provide documentation the emergency generator was tested for 30 minutes under load in December 2018 and May 2019.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the documentation was not available.


2. Document review on September 23, 2019, at 8:15 am, revealed the facility could not provide documentation indicating a 3-Year 4-Hour emergency generator exercise had been performed within the previous 36 months.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the documentation was not available.






 Plan of Correction - To be completed: 11/02/2019

The emergency generator will be tested in each calendar month versus every 30 days.
The 3 year, 4 hour testing was completed on October 7, 2019.
The results of the emergency testing will be reported at the QA meeting monthly times three for their review and recommendations.
The Director of Maintenance is responsible for this.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
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 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to ensure the unauthorized use of electrical equipment was prohibited, affecting 1 of 12 smoke zones within the facility.

Findings include:

1. Observation made on September 23, 2019, at 11:48 am, revealed inside the 1st floor business office, a refrigerator, coffee maker and a microwave oven were plugged into the same powerstrip.

Interview at the exit conference with the Assistant Administrator and the Maintenance Director on September 23, 2019 at 2:35 pm, confirmed the improper use of a powerstrip.





 Plan of Correction - To be completed: 11/02/2019

The appliances were immediately unplugged from the power strip and plugged directly into the wall outlet.
Random audits of appliances will be done monthly times three and the results reported at the QA meeting for their review and recommendations.
The Director of Maintenance is responsible for this.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port