Pennsylvania Department of Health
HOLY FAMILY HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 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 May 23, 2024, 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 May 23, 2024, it was determined that Holy Family Home - Health Care Building, Side -A was not in compliance with 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 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 observation, document review and interview, it was determined the facility failed to maintain the building construction requirements, affecting the entire facility.

Findings include:

Observation and document reviewed on May 23, 2024, 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 the Assistant Maintenance Director on May 23, 2024, at 10:45 a.m., confirmed the building construction type.

Plan of Correction - To be completed: 07/19/2024

Skilled unit was moved on 8/24/2023 from the five-story building to a newly constructed two-story fire protected, fully sprinklered, non-combustible building. This is a Type II(000)/II (111) fully sprinklered building constructed as per NFPA 220. Facility requests that DOH complete an updated FSES.

Side A (component 01) currently has no healthcare use as it is under construction. At the conclusion of construction, Side A (component 01) will be occupied again and under DOH jurisdiction, but the construction project reduces the height to a two-story building and upgrading the construction fire protection type to Type II (1,1,1). When finished the Side A (01 component) will be separated from the new independent living apartments, which are not under DOH jurisdiction.

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 May 23, 2024, it was determined that Holy Family Home - New 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 Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0131

Based on observation and interview, it was determined the facility did not maintain the fire resistance of fire rated doors, affecting one of three levels.

Findings include:

Observation on May 23, 2024, at 9:48 a.m., revealed the fire doors between components failed to latch.

Exit interview with the Administrator and the Assistant Maintenance Director on May 23, 2024, at 10:45 a.m., confirmed the doors failed to latch.

Plan of Correction - To be completed: 07/19/2024

Fire door will be adjusted to positively latch. Maintenance staff and supervisors will be in-serviced on necessity of fire doors to positively latch. Maintenance staff to monitor door weekly for a month and then monthly.

NFPA 101 STANDARD Illumination of Means of Egress:

Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8

Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0281

Based on document review and interview, it was determined the facility failed to maintain emergency lighting, affecting the entire component.

Findings include:

Document review on May 23, 2024, at 8:00 a.m., revealed the facility could not provide documentation of monthly 30 second testing.

Exit Interview with the Administrator and the Assistant Maintenance Director on May 23, 2024, at 10:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/19/2024

Emergency lighting is checked monthly. Documentation, which was not located when surveyor was on site, was e-mailed to DOH on 6/7/2024.

NFPA 101 STANDARD Cooking Facilities:

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: SKILLED ADDITION - Component: 02 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain kitchen hood suppression systems, affecting one three levels.

Findings include:

Observation on May 23, 2024, at 9:53 a.m., revealed the kitchen hood suppression system lacked monthly visual inspections.

Exit Interview with the Administrator and the Assistant Maintenance Director on May 23, 2024, at 10:45 a.m., confirmed the lack of monthly visual inspections.

Plan of Correction - To be completed: 07/19/2024

Kitchen (pantry) hood suppression system has been checked monthly and will now be documented. Maintenance Supervisor to monitor.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: SKILLED ADDITION - Component: 02 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire component.

Findings include:

Document review on May 23, 2024, at 8:00 a.m., revealed the facility failed to provide documentation of the following tests and inspections:

a. Monthly testing of battery electrolyte specific gravity or conductance;
b. Annual 90 minute load bank;
c. Preventative maintenance showing no evidence of wet stacking;
d. Annual fuel quality test.

Exit Interview with the Administrator and the Assistant Maintenance Director on May 23, 2024, at 10:45 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 07/19/2024

a. Battery electrolyte specific gravity/conductance is checked monthly. Documentation, which was provided but missed when surveyor was on site, was e-mailed to DOH on 6/7/2024.

b. Annual 90 minute load bank was done on 9/11/2023. Documentation, which was not located when surveyor was here, was e-mailed to DOH on 6/7/2024.

c. Preventative maintenance to check for evidence of wet stacking will be performed annually by contractor. Maintenance supervisor to monitor.

d. Annual fuel quality test will be scheduled. Maintenance supervisor to monitor.

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