Pennsylvania Department of Health
HILLTOP HEIGHTS HEALTH & REHAB CENTER
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.


HILLTOP HEIGHTS HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on a revisit to an Emergency Preparedness Survey completed on January 24, 2024, it was determined that Hilltop Heights Health and Rehab Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:

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.

§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..

Observations:
Name: - Component: -- - Tag: 0041

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, for six of the past 12 months, affecting the entire facility.

Findings include:

1. Review of documentation on January 24, 2024, at 11:30 a.m., revealed the facility failed to provide documentation at the time of the survey for the following required emergency generator testing for July through December 2023:

a) weekly battery voltage testing;
b) monthly battery conductance testing;
c) monthly automatic transfer switch testing.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed emergency generator testing deficiencies.

*** Note: During the revisit on March 18, 2024, at 11:00 a.m., it was determined that item 1. b had not been completed.

Interview with the Facility Administrator and the Maintenance Director on March 18, 2024, at 11:30 a.m., confirmed that listed item 1. b had not been completed.

Plan of Correction - To be completed: 03/19/2024

1. The facility is unable to correct the missed generator tests retrospectively however, the maintenance director and assistant will complete the weekly and monthly required testing. Ongoing.
2. The generator testing requirements (weekly, monthly, and annual) will be scheduled in advance by the maintenance director or designee for each month in 2024 with regard to the regulation. Ongoing.
3. The administrator will educate the Maintenance Director and Assistant on the regulation. Completed.
Documentation on January 24, 2024, at 11:30 a.m., revealed the facility failed to provide documentation at the time of the survey for the following required emergency generator testing for July through December 2024:
a) weekly battery voltage testing; In compliance on 3.18.24 revisit.
b) monthly battery conductance testing; Audit has been revised to exhibit documentation of monthly battery conductance testing. 3.19.2024
c) monthly automatic transfer switch testing. In compliance on 3.18.24 revisit.
4. The generator test completion and results will be reviewed by the maintenance director or designee in the monthly QAPI meetings. Ongoing.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 380502
Component 01
Main Building

Based on a revisit to a Medicare/Medicaid Recertification Survey completed on January 24, 2024, it was determined that Hilltop Heights Health and Rehab Center 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 (111), protected wood frame building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting two of five smoke compartments.

Findings include:

1. Observation on January 24, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:11 a.m., an inspection above the ceiling by the clean linen laundry room door revealed pipes were lying on top of the sprinkler branch line in the service hallway;
b) 9:12 a.m., an inspection above the ceiling by the soiled linen laundry room door revealed MC cables were lying on top of the sprinkler branch line in the service hallway;
c) 10:15 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system. There were multiple unsealed penetrations in the ceiling of the north hall equipment room by the nurse station.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies.

*** Note: During the revisit on March 18, 2024, at 9:50 a.m., it was determined that item 1. a had not been completed.

Interview with the Facility Administrator and the Maintenance Director on March 18, 2024, at 11:30 a.m., confirmed that listed item 1. a had not been completed.

Plan of Correction - To be completed: 03/19/2024

1a. The pipes lying on top of the sprinkler branch line in the clean linen laundry room were adjusted in height so they are not touching the branch line. This has been corrected. 3.19.24
353 1(b) and 1(c) were in compliance on 3.18.24 revisit.
2. A random audit of 5 other areas in the ceiling will be checked by the maintenance director of designee for unsealed penetrations in the ceiling and cables lying on top of the sprinkler branch lines. Completed.
3. The administrator will educate the Maintenance Director and Assistant on the regulation. Completed.
4. The results of the Life Safety Survey audits and education will be reviewed in the monthly QAPI meeting for 2 months.

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, it was determined the facility failed to maintain the two-hour fire rating of the emergency generator enclosure for one of one emergency generators, affecting the entire facility. Installation shale be in accordance with NFPA 101, 8.2.3 and NFP 110, 7.2.1.1

Findings include:

1. Observation on January 24, 2024, at 9:37 a.m., revealed the ceiling of the emergency generator room was not sealed around the emergency generator exhaust stack.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed emergency generator enclosure deficiency.

*** Note: During the revisit on March 18, 2024, at 10:05 a.m., it was determined that item 1. had not been completed.

Interview with the Facility Administrator and the Maintenance Director on March 18, 2024, at 11:30 a.m., confirmed that listed item 1. had not been completed.

Plan of Correction - To be completed: 03/19/2024

1.The ceiling penetration of the emergency generator exhaust stack was sealed by the maintenance director or designee. Completed. 3.19.24
2. There is only one generator room so there are no others to check.
3. The administrator will educate the Maintenance Director and Assistant on the regulation. Completed.
4. The results of the Life Safety Survey and progress of the plan of correction will be reviewed in the monthly QAPI meeting.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, for six of the past 12 months, affecting the entire facility.

Findings include:

1. Review of documentation on January 24, 2024, at 11:30 a.m., revealed the facility failed to provide documentation at the time of the survey for the following required emergency generator testing for July through December 2024:

a) weekly battery voltage testing;
b) monthly battery conductance testing;
c) monthly automatic transfer switch testing.

Interview with the Facility Administrator, Maintenance Supervisor, and Assistant Supervisor on January 24, 2024, at 1:30 p.m., confirmed the listed emergency generator testing deficiencies.

*** Note: During the revisit on March 18, 2024, at 11:00 a.m., it was determined that item 1. b had not been completed.

Interview with the Facility Administrator and the Maintenance Director on March 18, 2024, at 11:30 a.m., confirmed that listed item 1. b had not been completed.

Plan of Correction - To be completed: 03/19/2024

. The facility is unable to correct the missed generator tests retrospectively however, the maintenance director and assistant will complete the weekly and monthly required testing. Ongoing.
2. The generator testing requirements (weekly, monthly, and annual) will be scheduled in advance by the maintenance director or designee for each month in 2024 with regard to the regulation. Ongoing.

3. The administrator will educate the Maintenance Director and Assistant on the regulation. Completed.

Documentation on January 24, 2024, at 11:30 a.m., revealed the facility failed to provide documentation at the time of the survey for the following required emergency generator testing for July through December 2024:

a) weekly battery voltage testing; In compliance on 3.18.24 revisit.

b) monthly battery conductance testing; Audit has been revised to exhibit documentation of monthly battery conductance testing. 3.19.2024

c) monthly automatic transfer switch testing. In compliance on 3.18.24 revisit.

4. The generator test completion and results will be reviewed by the maintenance director or designee in the monthly QAPI meetings. Ongoing.

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