Pennsylvania Department of Health
 HOLY FAMILY HOME
Building Inspection Results

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HOLY FAMILY HOME
Inspection Results For:

There are  42 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.
HOLY FAMILY HOME - 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 April 15, 2025, at Holy Family Home, 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# 341602
Component 01
Health Care Building, Side-A

Based on a Medicare/Medicaid Recertification Survey completed on April 15, 2025, it was determined that Holy Family Home - Main Building 01, was not in compliance with the following requirements of the Life Safety Code for 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 five-story, Type II (000), unprotected, non-combustible building, with a penthouse and basement level, 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 - Component: 01 - Tag: 0161

Based on document review and interview, it was determined the facility failed to maintain the building construction requirements, affecting the entire facility.

Findings include:

Document review on April 15, 2025, at 9:30 a.m., revealed the building has been classified as a five story, Type II (000), unprotected non-combustible construction, which is fully sprinklered. The story height exceeds the maximum allowed for an unprotected non-combustible construction by three stories.

Exit Interview with the Administrator and Maintenance Director on April 15, 2025, at 12:30 p.m., confirmed the building construction type.






 Plan of Correction - To be completed: 06/14/2025

Side A (component 01) has been renovated and the project reduces the height to a two-story building and upgraded the construction fire protection type to Type II (1,1,1). Phase 2 Occupancy Survey for the renovated Side A (component 01) was completed on November 20, 2024 and approved. And the Side A (component 01) is now separated from the new independent living apartments, which are not under DOH jurisdiction. Facility requests that DOH complete an updated FSES.
NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on document review and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected and serviced at required intervals, affecting one of two components.

Findings include:

Document review on April 15, 2025, at 9:00 a.m., revealed the facility could not produce documentation showing the following kitchen components had been serviced as required:

a. 2- semi-annual kitchen suppression system inspections;
b. 2- semi-annual kitchen hood cleanings.

Exit Interview with the Administrator and Maintenance Director on April 15, 2025, at 12:30 p.m., confirmed the missing documentation.







 Plan of Correction - To be completed: 06/14/2025

a. Kitchen suppression system inspection was conducted on 5/23/2024 and 11/7/2024. Paperwork was not available at time of survey and will be requested from contractor. Maintenance supervisor will develop a schedule with subcontractor to conduct kitchen suppression system inspections on a biannual basis. Maintenance supervisor to monitor for compliance.

b. Kitchen hood cleaning was performed on 8/29/24. Paperwork was not available at time of survey and will be requested from contractor. Old kitchen in Component 01 was closed in December 2024 when new kitchen was put into operation. Therefore a second six month hood cleaning was not done on the old kitchen hood. Maintenance Supervisor will develop a schedule with subcontractor to conduct kitchen hood cleaning on a biannual basis on the new kitchen hood and will monitor for compliance.
NFPA 101 STANDARD Sprinkler System - 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.
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, document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of four quarters.

Findings include:

Document review on April 15, 2025, at 9:30 a.m., revealed the facility could not produce documentation showing quarterly sprinkler inspection had been performed- 1st quarter, 2025.

Exit Interview with the Administrator and Maintenance Director on April 15, 2025, at 12:30 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 06/14/2025

Contractor was contacted and sprinkler inspection has been scheduled. Will have contractor put us on an automatic quarterly inspection schedule. Maintenance supervisor to set up a checklist to track inspections and will contact contractor when inspection is overdue. Administrator to inservice Maintenance supervisor and staff. Maintenance supervisor to monitor.
NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to perform, fire drills, affecting one of twelve required drills.

Findings include:

Document review on April 15, 2025, at 9:30 a.m., revealed the facility could not provide documentation that a fire drill was conducted for the 2nd shift, 4th quarter 2024.

Exit Interview with the Administrator and Maintenance Director on April 15, 2025, at 12:30 p.m., confirmed the missing documentation.






 Plan of Correction - To be completed: 06/14/2025

A fire drill that was scheduled for 2nd shift, 4th quarter was changed and incorrectly scheduled for 1st shift.

Maintenance Supervisor will complete a schedule for the year and keep it in the fire drill binder. Any changes to the schedule must first be reviewed for compliance. Maintenance and administration staff to be in-serviced by administrator. Maintenance supervisor and administrator to monitor for compliance.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on document review and interview, it was determined the facility failed to properly conduct the required annual fire door inspection, for one required inspection.

Findings include:

Document review on April 15, 2025, at 9:30 a.m., revealed the facility lacked documentation showing that a complete annual fire door inspection was performed as required per NFPA 80.

Exit Interview with the Administrator and Maintenance Director on April 15, 2025, at 12:30 p.m., confirmed the incomplete documentation.





 Plan of Correction - To be completed: 06/14/2025

Checklist will be developed by maintenance supervisor, showing the list of items needed to be checked for a complete annual fire door inspection. Maintenance and administration staff to be in-serviced by administrator. Maintenance supervisor to monitor for compliance.


Initial comments:Name: SKILLED ADDITION - Component: 02 - Tag: 0000


Facility ID #341602
Component 02
New Addition

Based on a Medicare/Medicaid Recertification Survey completed on April 15, 2025, it was determined that Holy Family Home - Skilled Addition was not in compliance with the following requirements of the Life Safety Code for a new 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 (111), protected, non-combustible building, with a partial basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Fire Drills: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.
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7
Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0712

Based on document review and interview, it was determined the facility failed to perform, fire drills, affecting one of twelve required drills.

Findings include:

Document review on April 15, 2025, at 9:30 a.m., revealed the facility could not provide documentation that a fire drill was conducted for the 2nd shift, 4th quarter 2024.

Exit Interview with the Administrator and Maintenance Director on April 15, 2025, at 12:30 p.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 06/14/2025

A fire drill that was scheduled for 2nd shift, 4th quarter was changed and incorrectly scheduled for 1st shift.

Maintenance Director will complete a fire drill schedule for the year and keep it in the fire drill binder. Any changes to the schedule must first be reviewed for compliance. Maintenance and administration staff to be in-serviced by administrator. Maintenance supervisor and administrator to monitor for compliance.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
18.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (NFPA 80)
Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0761

Based on document review and interview, it was determined the facility failed to properly conduct the required annual fire door inspection, for one required inspection.

Findings include:

Document review on April 15, 2025, at 9:30 a.m., revealed the facility lacked documentation showing that a complete annual fire door inspection was performed as required per NFPA 80.

Exit Interview with the Administrator and Maintenance Director on April 15, 2025, at 12:30 p.m., confirmed the incomplete documentation.




 Plan of Correction - To be completed: 06/14/2025

Checklist will be created by maintenance supervisor, showing the list of items needed to be checked for a complete annual fire door inspection. Maintenance and administration staff to be in-serviced by administrator. Maintenance supervisor to monitor for compliance.


NFPA 101 STANDARD Electrical Systems - 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.
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 one 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: SKILLED ADDITION - Component: 02 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintain required testing of electrical receptacles, affecting the entire facility.

Findings include:

Document review on April 15, 2025, at 9:30 a.m., revealed electrical receptacles at patient bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months or hospital grade receptacles based on documented performance data, not exceeding 12 months. Receptacle testing should include the following:

a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Exit Interview with the Administrator and Maintenance Director on April 15, 2025, at 12:30 p.m., confirmed testing of electrical receptacles was not provided.




 Plan of Correction - To be completed: 06/14/2025

New checklist will be created to include the components to be tested for the electrical receptacles at patient bed locations. Maintenance and administration staff to be in-serviced. Maintenance supervisor to monitor for compliance.

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