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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CONEMAUGH MEMORIAL MEDICAL CENTER TRANSITIONAL CARE UNIT
Inspection Results For:

There are  39 surveys for this facility. Please select a date to view the survey results.

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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 March 27 and 28, 2024, 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 March 27 and 28, 2024, 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 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, affecting three of six floors.

Findings include:

1. Observation on March 27, 2024, at 9:32 a.m., revealed there were multiple penetrations above the fifth-floor access door inside the pipe chase enclosure.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on March 28, 2024, at 10:30 a.m., confirmed the listed vertical opening enclosure deficiency.






 Plan of Correction - To be completed: 04/11/2024

Sustainability will be achieved through Facility Sustainabilitity rounding. An example of expectations include verifying above ceiling program. Verification and follow-up will occur on the next scheduled rounds. Rounds are expected quarterly.
The Pipe chase penetrations have been sealed with the apporiate fire protection. This will be monitored at the quarterly TCU quality assurance meeting and report out there.

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 smoke barrier walls in four instances, affecting two of eight smoke compartments.

Findings include:

1. Observation on March 27, 2024, revealed multiple unsealed wire penetrations in the TCU unit smoke barrier walls, above the ceiling at the following smoke barrier door locations:

a) 10:13 a.m., door P 254 A;
b) 10:16 a.m., door P 246 A;
c) 10:22 a.m., door P 236 B;
d) 10:28 a.m., door P 236 A.

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on March 28, 2024, at 10:30 a.m., confirmed the listed smoke barrier wall deficiencies.







 Plan of Correction - To be completed: 04/11/2024

Sustainability will be achieved through Facility Sustainabilitity rounding. An example of expectations include verifying above ceiling program. Verification and follow-up will occur on the next scheduled rounds. Rounds are expected quarterly. A. Above Door P254Awas sealed with the appropriate fire proofing. B.Above Door P246Awas sealed with the appropriate fire proofing. C. Above Door P236Bwas sealed with the appropriate fire proofing. All conduits will be sealed. D. Above Door P236Awas sealed with the appropriate fire proofing. This will be monitored at the quarterly TCU quality assurance meeting and report out there.




NFPA 101 STANDARD Fire Drills: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.
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 documentation review and interview, it was determined the facility failed to meet the requirements for fire drills to be held at unexpected times and varying conditions for four of 12 fire drills that were performed over the past four quarters, affecting the entire facility.

Findings include:

1. Review of documentation on March 28, 2024, at 8:45 a.m., revealed that fire drills for the past four quarters for the second shift were all performed within a two-hour time frame (8:30 p.m. to 10:30 p.m.).

Interview with the Facility Administrator, Maintenance Director, and Facility Staff on March 28, 2024, at 10:30 a.m., confirmed the listed fire drill deficiency.





 Plan of Correction - To be completed: 04/11/2024

All Fire drills will be completed after a thorough review of previous drill times with the Lee Campus, Lead Mechanic in order to prevent an overlap.

This will be monitored at the quarterly TCU quality assurance meeting and report out there.


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