Nursing Investigation Results -

Pennsylvania Department of Health
SACRED HEART HOSPITAL TRANSITIONAL CARE FACILITY
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SACRED HEART HOSPITAL TRANSITIONAL CARE FACILITY
Inspection Results For:

There are  31 surveys for this facility. Please select a date to view the survey results.

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SACRED HEART HOSPITAL TRANSITIONAL CARE FACILITY - 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 17, 2019, at Sacred Heart Hospital Transitional Care Facility, 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# 195502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 17, 2019, it was determined that Sacred Heart Hospital Transitional Care Facility had deficiencies that have the potential for minimal harm as related to 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 an eight story, Type II (222), fire resistive building, with a basement, sub-basement, and rooftop mechanical spaces, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities: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.
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 maintain cooking facilities, affecting one of one floor.

Findings include:

1. Observation on September 17, 2019, at 11:00 a.m., revealed the facility lacked one of two kitchen suppression system inspection.

Exit interview with the facility administrator and the facilities manager on September 17, 2019, between 11:30 a.m., and 11:45 a.m., confirmed the cooking facilities deficiency.



 Plan of Correction - To be completed: 10/15/2019

1. The St. Luke's Sacred Heart (SLSH) Facilities Manager had scheduled a kitchen suppression inspection and this was completed on September 17, 2019.

2. The results of the kitchen suppression inspection were reviewed by SLSH Facilities Manager and the Nursing Home Administrator. The results indicated that there were no issues or recommendations.

3. The SLSH Facilities Manager has scheduled kitchen suppression inspections every 6 months, and the next inspection will be completed on March 2020.

4. The results of the kitchen suppression inspection will be reviewed by the Facility Manager and the Transitional Care Facility Quality Assurance team to assure compliance and to make additional recommendations.

NFPA 101 STANDARD Electrical Systems - 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0914

Based on observation and interview, it was determined the facility failed to maintain electrical systems, affecting one of one floor.

Findings include:

1. Observation on September 17, 2019, at 10:45 a.m., revealed the facility lacked required yearly receptacle testing data.

Exit interview with the facility administrator and the facilities manager on September 17, 2019, between 11:30 a.m., and 11:45 a.m., confirmed the electrical systems deficiency.



 Plan of Correction - To be completed: 10/15/2019

1. All the receptacles at St. Luke's Sacred Heart Transitional Care Facility will be tested, and a risk assessment will be completed by October 4, 2019.

2. An AD Hoc Facilities Management team will review the results, and determine the interval frequency of testing as defined by the documented performance data.

3. The results of receptacle testing will be reviewed by the Facility Manager and the Transitional Care Facility Quality Assurance team to assure compliance and to make additional recommendations.


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