Pennsylvania Department of Health
PROVIDENCE POINT HEALTHCARE RESIDENCE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PROVIDENCE POINT HEALTHCARE RESIDENCE - 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 August 5, 2024, at Providence Point Healthcare Residence, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: NCF - Component: 01 - Tag: 0000

Facility ID # 21600201
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on August 5, 2024, it was determined that Providence Point Healthcare Residence, 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 three-story, Type II (111), protected noncombustible building, with a basement and attic, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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 Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: NCF - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system, in one instance, affecting the entire facility

Findings Include:

1. Review of documentation on August 5, 2024, at 8:50 a.m., revealed the facility lacked documentation for the semi-annual fire alarm inspections.

Interview with the Administrator and Assistant Facility Maintenance Supervisor on August 5, 2024, at 1:30 p.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 09/13/2024

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

A Visual inspection to be completed by 8/21/24 by Director of EVS/Designee to verify location and condition of all fire system components

To prevent recurrence a Preventative Maintenance work order has been created and will be auto generated each July and January for audit to be completed by Director of Security/Designee.

Audits will be conducted semi-annually and filed with life safety documents.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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.

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: NCF - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barriers in one instance, affecting one of fifteen one smoke compartments.

Findings include:

1. Observation on August 5, 2024, at 11:15 a.m., revealed an unsealed electrical conduit, with an exposed wire, in the smoke wall above the smoke doors on B Pod, near Room 209.

Interview with the Facility Administrator and Assistant Maintenance Supervisor on August 5, 2024, at 1:30 p.m., confirmed the smoke barrier penetration.

Plan of Correction - To be completed: 09/13/2024

Penetration of smoke barrier was repaired with proper fire caulking on 8/5/24 by member of maintenance department.

In order to prevent recurrence, audits will be completed by EVS/Designee weekly for the next 4 weeks verifying there are no other smoke barrier penetrations.

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