Pennsylvania Department of Health
CHURCH OF GOD HOME INC
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CHURCH OF GOD HOME INC
Inspection Results For:

There are  41 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.
CHURCH OF GOD HOME INC - 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 7, 2024, at Church of God Home Inc, 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# 291602
Component 01
Original Building

Based on a Medicare/Medicaid Recertification Survey completed on March 7, 2024, it was determined the Church of God Home Inc 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 one-story, Type V (000), unprotected wood frame structure, with a basement, which is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100


28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation and interview on March 7, 2024, between 9:00 AM and 10:30 AM, revealed the facility life safety drawings lacked resident room capacities, hazardous areas, travel distance from the furthest point in the zone to the exit, travel distance from the furthest point in the zone to the smoke barrier doors, and length & width of zones.

Interview at the time of the exit conference with the Plant Operations Director and Administrator on March 7, 2024, at 1:30 PM confirmed the portable, accurate life safety drawings of the facility did not contain all required information.




 Plan of Correction - To be completed: 05/01/2024

Noelker and Hull were contacted on 3/11 for architectural prints with dimensions. Those drawings were expected to be received by 3/31/24. The drawings have already been received from but are missing dimensions. The Vice President for Physical Plant and Engineering will contact Life Safety by 3/22/24 for the microfiche files to have drawings reprinted. Anticipated date to receive all drawings is 5/1/24. Once the files are updated, they will be maintained with any future regulatory updates.
NFPA 101 STANDARD Number of Exits - Story and Compartment: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.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0241

Based on observation and interview, it was determined the facility failed to maintain the required number of exit egress routes, for one of two floors within the component.

Findings include:

1. Observation on March 7, 2024, between 11:30 AM and 12:15 PM, revealed the basement, located below the Kitchen, lacked two acceptable means of egress.

Interview at the time of the exit conference with the Plant Operations Director and Administrator on March 7, 2024, at 1:30 PM, confirmed the basement lacked 2 exits.


 Plan of Correction - To be completed: 04/19/2024

**UPDATE 4/2/24: The facility wishes to have DSI conduct and FSES survey.

* UPDATE: This facility contacted DSI on 3/27/24 to obtain the microfiche of the original drawings. An FSES survey was previously conducted and a letter was obtained for that survey from the Harrisburg Field Office on 4/11/2022. This letter will be maintained for future surveys.

The Vice President of Plant Operations and Engineering will contact RLPS Architects to verify where a second means of egress will need to be located under the kitchen. Contact will be made by 3/22/23. Site confirmation/consultation of existing prints will occur before 4/19/24. If construction is needed, it will be followed by Life Safety approved prints. Construction completion date is anticipated by 9/31/24.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar: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.
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 - Component: 01 - Tag: 0371

Based on observation and interview, it was determined the facility failed to provide smoke compartments, not greater than 22,500 square feet, affecting two of two floors within the component.

Findings include:

1. Observation on March 7, 2024, between 10:45 AM and 11:45 PM, revealed the facility lacked smoke barrier walls on the ground floor.

Interview at the time of the exit conference with the Plant Operations Director and Administrator on March 7, 2024, at 1:30 PM, confirmed the ground floor did not have smoke barrier walls.



 Plan of Correction - To be completed: 04/19/2024

**UPDATE 4/2/24: The facility wishes to have DSI conduct and FSES survey.

* UPDATE: This facility contacted DSI on 3/27/24 to obtain the microfiche of the original drawings. An FSES survey was previously conducted and a letter was obtained for that survey from the Harrisburg Field Office on 4/11/2022. This letter will be maintained for future surveys.

The Vice President of Plant Operations and Engineering will contact RLPS Architects to verify where a smoke compartment shall be established on the ground floor. Contact will be made by 3/22/24. Site visit/consultation of existing prints will occur before 4/19/24. If construction is needed, it will be followed by Life Safety approved prints. Construction completion date is anticipated by 9/31/24.
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 Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier door hardware to function per manufacturer specifications, in three of three smoke compartments within the component.

Findings include:

1. Observation on March 7, 2024, between 11:15 AM and 11:25 AM, revealed smoke barrier doors were equipped with latching hardware, which failed to close and latch in the frame, at the following locations:

a. 11:15 AM, attic, Faith west smoke wall;
b. 11:25 AM, attic, Faith east smoke wall.

Interview at the time of the exit conference with the Plant Operations Director and Administrator on March 7, 2024, at 1:30 PM, confirmed the smoke door hardware failed to function, per manufacturer's specifications.



 Plan of Correction - To be completed: 03/31/2024

The Vice President of Plant Operations and Engineering will work with the maintenance staff at the facility to install gate springs on the attic doors so that they self-close by 3/31/24. Audits will include 2 random attic doors at the smoke walls monthly for 3 months, then quarterly until March 2025. Attic doors will be checked annually thereafter.
Initial comments:Name: LOVE WING - Component: 02 - Tag: 0000

Facility ID #291602
Component 02
Love Wing

Based on a Medicare/Medicaid Recertification Survey completed on March 7, 2024, it was determined the Church of God Home Inc had deficiencies that have the potential for minimal harm as related to the following requirements of the Life Safety Code for 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 two-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other: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.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
Name: LOVE WING - Component: 02 - Tag: 0100


28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation and interview on March 7, 2024, between 9:00 AM and 10:30 AM, revealed the facility life safety drawings lacked resident room capacities, hazardous areas, travel distance from the furthest point in the zone to the exit, travel distance from the furthest point in the zone to the smoke barrier doors and length & width of zones.

Interview at the time of the exit conference with the Plant Operations Director and Administrator on March 7, 2024, at 1:30 PM, confirmed the portable, accurate life safety drawings of the facility did not contain all required information.



 Plan of Correction - To be completed: 05/01/2024

Noelker and Hull were contacted on 3/11 for architectural prints with dimensions. Those drawings were expected to be received by 3/31/24. The drawings have already been received from but are missing dimensions. The Vice President for Physical Plant and Engineering will contact Life Safety by 3/22/24 for the microfiche files to have drawings reprinted. Anticipated date to receive all drawings is 5/1/24. Once the files are updated, they will be maintained with any future regulatory updates.


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