Pennsylvania Department of Health
 PHOEBE WYNCOTE
Building Inspection Results

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PHOEBE WYNCOTE
Inspection Results For:

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PHOEBE WYNCOTE - 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 12, 2024, at Phoebe Wyncote, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.






 Plan of Correction:


Initial comments:Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0000


Facility ID# 232102
Component 02
Cassell Hall and Berger Hall

Based on a Medicare/Medicaid Recertification Survey completed on March 12, 2024, it was determined that Phoebe Wyncote 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 two-story, Type V (000), unprotected wood frame building, with a basement and an attic, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height: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.
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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - 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:

Observation and document review on March 12, 2024, between 8:30 a.m. and 10:00 a.m., revealed the facility had been classified as a two-story, Type V (000), unprotected wood frame construction, with a basement, that is fully sprinklered. The building exceeds the maximum allowable story height for this type of construction by one story.

Exit Interview with the Administrator and Maintenance Director on March 12, 2024, at 12:15 p.m., confirmed the building construction type.





 Plan of Correction - To be completed: 04/26/2024

* Phoebe Wyncote requests this deficiency be part of the Department of Health provided FSES, as the building height cannot be altered.

* Phoebe Wyncote requests that the DOH complete the FSES for this deficiency.

NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0211

Based on observation, document review, and interview, it was determined the facility failed to maintain the minimum headroom clearance of the exit access corridor, affecting one out of five smoke compartments.

Findings include:

Observation and document review on March 12, 2024, between 10:00 a.m. and 10:30 a.m., revealed the headroom clearance within the corridors of the basement level, near the maintenance office and similar staff areas, measured at six feet at the ramp leading to the laundry, which was less than the minimum height requirement of six feet-eight inches.

Exit Interview with the Administrator and Maintenance Director on March 12, 2024, at 12:15 p.m., confirmed the ceiling height was less than the minimum required.




 Plan of Correction - To be completed: 04/26/2024

* Phoebe Wyncote requests this deficiency be part of the Department of Health provided FSES, as the ceiling height cannot be altered.

* Phoebe Wyncote requests that the DOH complete the FSES for this deficiency.

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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of three levels.

Findings include:

Observation on March 12, 2024, at 10:20 a.m., revealed, on the first floor, above the smoke doors by the ramp, an unsealed penetration around a data wire bundle.

Exit Interview with the Administrator and Maintenance Director on March 12, 2024, at 12:15 p.m., confirmed the penetration.





 Plan of Correction - To be completed: 04/26/2024

* Penetration will be sealed via UL listed system.

* Maintenance will conduct 100% audit of all fire wall separations to ensure all penetrations are sealed.

* Maintenance will conduct quarterly audits of all fire walls to ensure all penetrations are sealed and present results in QAPI x 4.

NFPA 101 STANDARD Electrical Systems - Other: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 - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems 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.
Chapter 6 (NFPA 99)
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting two of three levels.

Findings include:

Observations on March 12, 2024, revealed the following electrical deficiencies:

a. 11:00 a.m., basement glove storage room, electrical panel missing its protective blank.
b. 11:50 a.m., on the first floor, social services office, 3-prong adapter plugged into duplex receptacle.

Exit Interview with the Administrator and Maintenance Director on March 12, 2024, at 12:15 p.m., confirmed the electrical deficiencies.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.




 Plan of Correction - To be completed: 04/26/2024

Part A Below

*A* Circuit panel blank has been placed on panel in basement glove storage room.

*A* Will conduct 100% audit of all electric panels to ensure there are no missing panel blanks.

*A* Maintenance will conduct a quarterly audit to ensure panels are not missing any blanks and present results in QAPI x 4.


Part B Below

*B* 3-Prong adapter was removed during inspection in social worker's office.

*B* Maintenance will conduct 100% audit of all office outlets to ensure there are no unapproved devices in use.

*B* Maintenance will conduct a quarterly audit to ensure office outlets are not using unapproved devices and present results in QAPI x 4.


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: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0914

Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested at patient bed locations within the facility.

Findings include:

Document review on March 12, 2024, at 9:30 a.m., revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested as required for non-hospital grade receptacles at intervals not exceeding 12 months. Receptacle testing should include the following:

a. visual inspection of physical integrity.
b. correct polarity of the hot and neutral connections.
c. retention force of the grounding blade (except locking-type receptacles) shall not be less than 4 oz.

*The facility failed to conduct and document the (c.) retention portion of receptacle testing.

Exit Interview with the Administrator and Maintenance Director on March 12, 2024, at 12:15 p.m., confirmed testing of electrical receptacles was incomplete.




 Plan of Correction - To be completed: 04/26/2024

* Outlet retention testing will be conducted and documented by 04/26/2024.

* Outlet retention testing will be added to annual outlet inspections. Any outlet that does not meet retention requirements will be replaced with a new outlet. The new outlet will be tested after installation.

* Maintenance will present results in QAPI X 1.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: (BLDG 02 CASSEL HALL & BERGER HALL) - Component: 02 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain oxygen cylinder storage, affecting two of three levels.

Findings include:

Observation on March 12, 2024, revealed unsecured and freestanding oxygen cylinders in the following locations:

a. 11:15 a.m., on the first floor, Med-Tech office- 3 cylinders.
b. 11:25 a.m., on the second floor, oxygen storage- 3- cylinders.

Exit Interview with the Administrator and Maintenance Director on March 12, 2024, at 12:15 p.m., confirmed the unsecured cylinders.




 Plan of Correction - To be completed: 04/26/2024

* All three oxygen cylinders located in Med Tech office were moved to the secured empty oxygen tank storage rack in oxygen storage room during inspection.

* Staff will be trained on where to place empty oxygen cylinders. Training will be documented.

* Maintenance will conduct a monthly audit to ensure all oxygen tanks are in a secured rack.

* Maintenance will present results in QAPI x 4.




* All three oxygen cylinders in oxygen storage room were moved into the secured empty oxygen tank rack during inspection.

* Staff will be trained on where to place empty oxygen cylinders. Training will be documented.

* Maintenance will conduct a monthly audit to ensure all oxygen tanks are in a secured rack.

* Maintenance will present results in QAPI x 4.


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