Pennsylvania Department of Health
DRESHER HILL HEALTH & REHABILITATION CENTER
Building Inspection Results

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DRESHER HILL HEALTH & REHABILITATION CENTER
Inspection Results For:

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DRESHER HILL HEALTH & REHABILITATION 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 23, 2024, at Dresher Hill Health and Rehabilitation 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 - Component: 01 - Tag: 0000


Facility ID# 271202
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 23, 2024, it was determined that Dresher Hill Health & Rehabilitation Center 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 II (000), unprotected, noncombustible building, with a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - 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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, the facility failed to maintain hazardous area enclosures on one of three building levels.

Findings include:

Observation on January 23, 2024, at 11:45 a.m., revealed on the first floor, low side, oxygen storage room door failed to close and latch in the frame.

Exit interview with the Administrator and the Maintenance Supervisor on January 23, 2024, at 12:50 p.m., confirmed the above door deficiency.





 Plan of Correction - To be completed: 02/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1. Facility fixed 1st Floor oxygen storage room door to properly self-close and latch.

2. To identify other areas with the potential to be affected, Maintenance Director inspected all oxygen storage room doors.

3. To prevent this from reoccurring, Administrator/designee educated Maintenance Department on ensuring doors properly self-close and latch.

4. For ongoing monitoring for compliance, Administrator/designee will audit oxygen storage room doors to properly self-close and latch weekly for 4 weeks, then monthly for 2 months.

5. Audit results will be reviewed by QAPI committee.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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 - Component: 01 - Tag: 0353

Based on observation and interview, the facility failed to maintain fire sprinkler heads for one of over 100 fire sprinkler heads.

Findings include:

Observation on January 23, 2024, at 11:46 a.m., revealed on the first floor, low side stairwell, had a damaged ceiling tile with a large opening, which can delay the activation of the nearby sprinkler head.

Exit interview with the Administrator and the Maintenance Supervisor on January 23, 2024, at 12:50 p.m., confirmed the damaged ceiling tile at the above location.






 Plan of Correction - To be completed: 02/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1. Facility replaced ceiling tile in 1st Floor low side stairwell.

2. To identify other areas with the potential to be affected, Maintenance Director inspected ceiling tiles in all stairwells.

3. To prevent this from reoccurring, Administrator/designee educated Maintenance Department on fire penetrations.

4. For ongoing monitoring for compliance, Administrator/designee will audit ceiling tiles in stairwells weekly for 4 weeks, then monthly for 2 months.

5. Audit results will be reviewed by QAPI committee.


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 - Component: 01 - Tag: 0372

Based on document review, observation and interview, the facility failed to maintain fusible-link fire damper inspections affecting four of over twenty fire dampers.

Findings include:

Document review on January 23, 2024, at 11:04 a.m., revealed the most recent fire damper inspection report (dated 10/21/20) indicated the following deficiencies requiring action: "Fire dampers 73, 74, 75, & 76 (Rooms 107, 115, 112) were not inspected 10/21/20 per the customers request. These dampers need to be inspected as soon as possible."

Exit interview with the Administrator and Maintenance Supervisor on January 23, 2024, at 12:50 p.m., confirmed the deficiency listed above existed.









 Plan of Correction - To be completed: 02/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1. Fire damper inspection scheduled for 02/12/2024

2. To identify other areas with the potential to be affected, Maintenance Director reviewed damper inspection including deficiencies noted at time of inspection.

3. To prevent this from reoccurring, Administrator/designee educated Maintenance Department on reviewing inspection reports and ensure any deficiencies noted are completed.

4. For ongoing monitoring for compliance, Administrator/designee will audit fire damper inspection and reports monthly for 3 months.

5. Audit results will be reviewed by QAPI committee.

NFPA 101 STANDARD Electrical Systems - 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.
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: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on three of three levels.

Findings include:

Observation on January 23, 2024, between 11:15 a.m. and 12:34 p.m., revealed the following electrical deficiencies:
A. (11:15 a.m.) on the second floor, above the smoke barrier doors next to resident room 202, had an unsecured junction box;
B. (11:28 a.m.) second floor, next to resident room 233, had exposed wiring on the light fixture;
C. (11:35 a.m.) on the second floor, beautician room, had two GFCI's with visual signs of burnt markings, an indication of overheating;
D. (11:42 a.m.) on the first floor, above the elevators, had open/ exposed splices;
E. (12:15 p.m.) basement, industrial fan cord, had a damaged cord with a non-rated splice and tape repairs;
F. (12:25 p.m.) in the basement, boiler/ mechanical room, had an unused cord that was hard wired into a junction box, with an exposed plug end;
G. (12:26 p.m.) in the basement, boiler/ mechanical room, had a non-terminated section of flexible metal conduit above the hot water tank;
H. (12:34 p.m.) in the basement, kitchen, hot plate cart, had a damaged section of insulation on the cord.

Reference: NFPA 70-400.9, NFPA 70-300.12, NFPA 70-200.3, NFPA 314.23 and NFPA 70-400.2

Exit interview with the Administrator and Maintenance Supervisor on January 23, 2024, at 12:34 p.m., confirmed the above electrical system deficiencies.












 Plan of Correction - To be completed: 02/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1. Facility completed the following:
a. Secured junction box on 2nd floor
located next to room 202
b. Removed exposed wire on light fixture on 2nd floor located next to room 233
c. Replaced two GFCI outlets in 2nd floor beautician room on 01/25/24
d. Secured wire in electrical box on 1st floor above the elevators
e. Placed lock out tag out on industrial fan. Fan was removed from basement area.
f. Removed cord in basement boiler room disconnect cord from outlet. Removed outlet.
g. Removed flexible metal conduit from junction box in basement boiler room
h. Repaired cord on hot plate cart located in basement kitchen

2. To identify other areas with the potential to be affected, Maintenance Director completed house audit of outlets, junction boxes, and equipment cords

3. To prevent this from reoccurring, Administrator/designee educated Maintenance Department on electrical system requirements per NFPA 70 and NFPA 99

4. For ongoing monitoring for compliance, Administrator/designee will audit for junction boxes, light fixtures, outlets, and equipment cords weekly for 4 weeks then monthly for 2 months.

5. Audit results will be reviewed by QAPI committee.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens: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.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain appropriate electrical power cords on three of three levels.

Findings include:

Observation on January 23, 2024, between 11:19 a.m. and 12:28 p.m., revealed the following electrical power cord deficiencies:
A. (11:19 a.m.) on the second floor, low side, nursing supervisor's office, had a refrigerator plugged into a surge protector;
B. (11:22 a.m.) on the second floor, physical therapy office, had a laptop plugged into an extension cord;
C. (12:01 p.m.) on the first floor, business managers office, had a surge protector plugged into a surge protector;
D. (12:28 p.m.) in the basement, boiler/ mechanical room, had an extension cord being used to power the trickle charge for the generator battery.

Exit interview with the Administrator and Maintenance Supervisor on January 23, 2024, at 12:50 p.m., confirmed the above power cord deficiencies existed.








 Plan of Correction - To be completed: 02/20/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1. Facility completed the following:
a. Removed surge protector from 2nd floor nursing supervisor office. Relocated fridge to proper wall outlet
b. Removed extension cord from 2nd floor therapy office. Relocated laptop to proper wall outlet
c. Removed surge protector from 1st floor business office. Installed 4gang electrical box.
d. Removed extension cord from basement boiler room. Installed new duplex outlet to side of generator


2. To identify other areas with the potential to be affected, Maintenance Director completed house audit for extension cords and surge protectors.

3. To prevent this from reoccurring, Administrator/designee educated staff on not using extension cords and surge protectors.

4. For ongoing monitoring for compliance, Administrator/designee will audit for extension cords and surge protectors weekly for 4 weeks then monthly for 2 months.

5. Audit results will be reviewed by QAPI committee.


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