Nursing Investigation Results -

Pennsylvania Department of Health
CONEMAUGH MEMORIAL MEDICAL CENTER TRANSITIONAL CARE UNIT
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CONEMAUGH MEMORIAL MEDICAL CENTER TRANSITIONAL CARE UNIT
Inspection Results For:
There are 34 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.


CONEMAUGH MEMORIAL MEDICAL CENTER TRANSITIONAL CARE UNIT - 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 May 5, 2022, at Conemaugh Memorial Medical Center-Transitional Care Unit, 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# 20760201
Component 01
Lee Campus-TCU on the 2nd floor

Based on a Medicare/Medicaid Recertification Survey completed on May 5, 2022, it was determined that Conemaugh Memorial Medical Center-Transitional Care Unit, 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 six-story, Type II (222), fire resistive building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

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.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to install carbon monoxide alarms in close-proximity to fossil fuel-burning devices (But not greater than 15 feet) in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act, in two instances, affecting the entire facility.

Findings include:

1. Review and Interview on May 5, 2022, at 9:30 a.m., revealed the facility failed to install carbon monoxide alarms in the following locations that support the Long Term Care Unit (TCU):

a) in the boiler room, located on the sixth floor;
b) in the emergency generator room, located on the sixth floor;

Interview with the Facility Administrator and Maintenance Staff on May 5, 2022, at 1:30 p.m., confirmed the facility failed to provide carbon monoxide alarms in required locations.

Plan of Correction - To be completed: 07/31/2022

The required carbon monoxide detectors will be installed in the boiler room (sixth floor) and the emergency generator room (sixth floor). All required devices will be tested and documented monthly per the Carbon Monoxide Policy.

Sustainability will be achieved through monthly inspection and testing along with application of required documentation. The Environment of Care Committee is responsible for oversight and implementing performance improvement. This process is in addition to ongoing compliance surveying and is reviewed at the Environment of Care Committee.
Completion Date: July 31, 2022

NFPA 101 STANDARD Vertical Openings - Enclosure:

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.

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in one instance, on one of five floors.

Findings include:

1. Observation on May 5, 2022, at 9:15 a.m., revealed a penetration in the pipe chase enclosure on the fifth floor.

Interview with the Facility Administrator and Maintenance Staff on May 5, 2022 at 1:30 p.m., confirmed the vertical enclosure penetration.

Plan of Correction - To be completed: 05/09/2022

Penetration in sixth floor pipe chase has been sealed with fire rated material. Documentation is on file at the facility.

Sustainability will be achieved through monthly inspection and testing along with application of required documentation. The Environment of Care Committee is responsible for oversight and implementing performance improvement. This process is in addition to ongoing compliance surveying and is reviewed at the Environment of Care Committee.
Completion Date: May 9, 2022

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