Pennsylvania Department of Health
PHOEBE RICHLAND HEALTH CARE CENTER
Building Inspection Results

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PHOEBE RICHLAND HEALTH CARE CENTER
Inspection Results For:

There are  48 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.
PHOEBE RICHLAND HEALTH CARE CENTER - 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 January 22, 2024 at Phoebe Richland Health Care Center, 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 (AREAS A,B,C,D, E, AND F) - Component: 01 - Tag: 0000


Facility ID# 260302
Component 01
Areas A, B, C, D, E, F and G

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, it was determined that Phoebe Richland Health Care Center - Areas A, B, C, D, E, F and G, were 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, 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: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain the construction requirements for an unprotected wood frame building, affecting the entire building component.

Findings include:

Document review on January 22, 2024, at 9:30 a.m., revealed Areas A, B, C, D, E, F and G were classified as a two story, Type V (000), unprotected wood frame building, that is fully sprinklered. The story height exceeds the maximum allowance for this construction type by one story.

Exit Interview with the Administrator and Maintenance Director on January 22, 2024, at 12:50 p.m., confirmed story height exceeded the maximum allowance for this construction type.




 Plan of Correction - To be completed: 03/12/2024

The facility wishes to continue the approved FSES on file and requests for an inspection to occur at a date to be scheduled by the DOH life safety team.

NFPA 101 STANDARD Means of Egress - General: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.
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: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments, affecting one of four emergency exits.

Findings include:

Observation on January 22, 2024, at 11:20 a.m., revealed emergency exit by room 201 egress path was obstructed by ice buildup.

Exit Interview with the Administrator and Maintenance Director on January 22, 2024, at 12:50 p.m., confirmed the obstructed egress path.






 Plan of Correction - To be completed: 03/12/2024

Egress was de-iced post the observation by a Maintenance Team Member. Other facility egresses were checked and cleared, as needed, to ensure they were free of any ice. After inclement weather, egresses will be checked by the EVS Director/designee x3 months to ensure they are free of any ice. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations x 3 months.

NFPA 101 STANDARD Emergency Lighting: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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) - Component: 01 - Tag: 0291

Based on observation and interview it was determined the facility failed to ensure battery back-up lighting was maintained, affecting one of two levels.

Findings include:

Observation on January 22, 2024, at 11:45 a.m., revealed, in the Lobby, the battery back-up lights failed to illuminate when tested.

Exit Interview with the Administrator and Maintenance Director on January 22, 2024, at 12:50 p.m., confirmed the battery back-up light failed to illuminate when tested.






 Plan of Correction - To be completed: 03/12/2024

The batteries for the back up lights were replaced on 1/23/2024 by Maintenance Supervisor. Emergency back up lights will be checked during monthly inspections to ensure proper functioning by a Maintenance team member. If they fail to illuminate, batteries will be replaced. Batteries for the back up lights will be replaced yearly. Monthly inspection results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations x 3 months.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain sprinkler system components, affecting the entire facility.

Findings include:

Document review on January 22, 2024, at 9:30 a.m., revealed the July 21, 2023, Annual sprinkler inspection report listed the following deficiency. Evidence of corrective action was not available at time of survey: " System #1 and System #2 contain non-listed antifreeze solution. "

Exit Interview with the Administrator and Maintenance Director on January 22, 2024, at 12:50 p.m., confirmed the sprinkler system deficiency.





 Plan of Correction - To be completed: 03/12/2024

The third party vendor is surveying the sprinkler system based upon the 2023 NFPA code requirements. Both glycol systems for the Cottage where tested on 1/25/2024. Once the test results are received, the facility will review to ensure they meet the current DOH Life Safety surveyed NFPA code requirements. If the results are not NFPA code-compliant with the edition surveyed by the DOH Life Safety, deficiencies will be corrected. Sprinkler inspection reports will be reviewed by the EVS director/designee post each test to ensure compliance. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations quarterly x2.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: MAIN BUILDING 01 (AREAS A,B,C,D, E, AND F) - Component: 01 - Tag: 0371

Based on document review and interview, it was determined the facility failed to maintain required travel distances within smoke compartments, for fully sprinklered buildings, affecting one of seven smoke compartments.

Findings include:

Document review on January 22, 2024, at 9:30 a.m., revealed the Area A/Gateway travel distance was in excess of 200 feet in length.

Exit Interview with the Administrator and Maintenance Director on January 22, 2024, at 12:50 p.m., confirmed the excessive travel distance.





 Plan of Correction - To be completed: 03/12/2024

The facility wishes to continue the approved FSES on file and requests for an inspection to occur at a date to be scheduled by the DOH life safety team.

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 01 (AREAS A,B,C,D, E, AND F) - Component: 01 - 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 two levels.

Findings include:

Observation on January 22, 2024, at 12:00 p.m., revealed, on the first floor, above the smoke doors by room 126, an unsealed penetration around data wire bundle.

Exit Interview with the Administrator and Maintenance Director on January 22, 2024, at 12:50 p.m., confirmed the penetration.




 Plan of Correction - To be completed: 03/12/2024

The cited unsealed penetration will be filled with proper product using TPFS by a Maintenance team member. Other firewalls will be reviewed by EVS Director / designee to ensure there are no unsealed penetrations. Unsealed penetrations will be filled with proper product using TPFS. Random audits of firewalls will be conducted by the EVS Director / designee to ensure penetrations are properly sealed monthly x 3 months. Unsealed penetrations will be filled with proper product using TPFS. Results will be reported by the EVS Director/Designee to the QAA Committee for review and further recommendations x 3 months.

Initial comments:Name: BUILDING 02 (COTTAGE AREA J) - Component: 02 - Tag: 0000


Facility ID# 260302
Component 02
Cottage Area J

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, at Phoebe Richland Health Care Center - Cottage Area J, it was determined that there were no deficiencies identified under the 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 one-story, Type V (111), protected wood frame building, that is fully sprinklered.





 Plan of Correction:


Initial comments:Name: BUILDING 03 (KITCHEN ADDITION AREA H) - Component: 03 - Tag: 0000


Facility ID# 260302
Component 03
Kitchen Addition Area H

Based on a Medicare/Medicaid Recertification Survey completed on January 22, 2024, at Phoebe Richland Health Care Center - Kitchen Addition Area H, it was determined there were no deficiencies identified under the 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 one-story, Type II (111), protected noncombustible building, that is fully sprinklered.





 Plan of Correction:



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