Pennsylvania Department of Health
OXFORD HEALTH CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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OXFORD HEALTH 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 February 21, 2024, at Oxford Health 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 - Component: 01 - Tag: 0000

Facility ID #410302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that Oxford Health 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 two-story, Type II (000), unprotected noncombustible structure, 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, observation 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, observation and interview on February 21, 2024, between 8:45 AM and 10:45 AM, revealed the facility lacked documentation of annual testing and inspection of installed Carbon Monoxide Alarms, per manufactures instructions, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of documentation annual inspections were not done.

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

1. The Annual Functional Fire inspection, conducted by PYE Barker is scheduled for March 21, 2024. This inspection will include testing of the carbon monoxide alarms.
2. The Maintenance Manager shall maintain a file with all inspections' and results, including any repairs that may be required. The annual inspection will be added to the Facilities preventive maintenance schedule for tracking.
3. The Director of Environmental Services shall report the results of all inspections and results at the Facilities QAPI meetings

NFPA 101 STANDARD Emergency Lighting:

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.

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility lacked installed battery back-up emergency lighting at the transfer switch and emergency generator, affecting the entire component.

Findings include:

1. Observation on February 21, 2024, between 11:35 AM and 11:45 AM, lacked an installed battery back-up emergency lighting, at the following locations:

a. 11:35 AM, basement, Electrical/Transfer Switch Room;
b. 11:45 AM, exterior, generator enclosure.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of battery back-up emergency lighting.

Plan of Correction - To be completed: 03/01/2024

1. Emergency lighting with a battery backup was installed on 2/28/2024 at the basement Electrical/Transfer Switch and in the exterior generator enclosure.
2. The Maintenance Manager will audit the operation of the emergency lighting monthly, including an annual 90 minute testing of the emergency lighting.
3. The Director of Environmental Services shall report the results of the monthly audits at the Facilities QAPI meetings

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain documentation verifying the sensitivity of smoke detectors had been tested within the previous two years, affecting the entire component.

Findings include:

1. Review of documentation on February 21, 2024, between 8:45 AM and 10:45 AM, revealed the facility failed to maintain documentation verifying the sensitivity of smoke detectors had been tested. Facility lacked documentation from the fire alarm company stating it was fully addressable and self-monitoring for sensitivity.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of documentation.

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

1. The Annual Functional Fire inspection, conducted by PYE Barker is scheduled for March 21, 2024. This inspection will include sensitivity of the smoke detectors. Documentation from the testing shall include that the smoke detectors are fully addressable and self-monitoring for sensitivity.
2. The Maintenance Manager shall maintain a file with all inspections' and results, including any repairs that may be required. The annual inspection will be added to the Facilities preventive maintenance schedule for tracking.
3. The Director of Environmental Services shall report the results of all inspections and results at the Facilities QAPI meetings

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 - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide 5-year sprinkler testing documentation, and sprinkler system to be free of obstructions, affecting the entire component.

Findings include:

1. Review of documentation on February 21, 2024, between 9:15 AM and 9:17 AM, revealed the facility lacked documentation of the following testing and inspections:

a. 9:15 AM, 5-year, internal pipe inspection;
b. 9:17 AM. 5-year, internal valve inspection.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the facility could not provide documentation of the 5-year internal inspections.

2. Observation on February 21, 2024, at 11:20 AM, revealed the basement Laundry Room Dryer Chase sprinkler heads (2) were covered with debris.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the sprinkler heads were loaded with debris.

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

1. The 5 year internal pipe and valve inspection was completed on 4/26 � 4/27/2023. Report available upon request.
2. The Maintenance Manager shall maintain a file with all inspections' and results, including any repairs that may be required. This inspection will be added to the Facilities preventive maintenance schedule for tracking. The results of the 5 year test will be included in the life safety book.
3. The Director of Environmental Services shall report the results of all inspections and results at the Facilities QAPI meetings.

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 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide the annual fuel quality analysis report for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on February 21, 2024, between 8:45 AM and 10:45 AM, revealed the facility lacked documentation for the annual fuel quality test. A sample was taken on June 7, 2023, but the facility never received the analysis report.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of documentation for emergency generator fuel analysis.

Plan of Correction - To be completed: 04/30/2024

1. The annual fuel sample test was drawn on 06/23/2023 and sent to the testing laboratory for analysis. At some point the sample was lost. A new sample was taken on 01/24/2024 and sent to the lab for analysis. Results from the testing of the 01/24/2024 sample are not expected until April.
2. The Maintenance Manager shall maintain a file with all inspections' and results, including any repairs that may be required. The annual inspection will be added to the Facilities preventive maintenance schedule for tracking.
3. The Director of Environmental Services shall report the results of all inspections and results at the Facilities QAPI meetings.

Initial comments:Name: CHAPEL - Component: 02 - Tag: 0000

Facility ID #410302
Component 02
Chapel Building

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that Oxford Health 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 II (111), protected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Observations:
Name: CHAPEL - 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, observation 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, observation and interview on February 21, 2024, between 8:45 AM and 10:45 AM, revealed the facility lacked documentation of annual testing and inspection of installed Carbon Monoxide Alarms, per manufactures instructions, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of documentation annual inspections were not done.

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: CHAPEL - Component: 02 - Tag: 0291

Based on observation and interview, it was determined the facility lacked installed battery back-up emergency lighting at the transfer switch and emergency generator, affecting the entire component.

Findings include:

1. Observation on February 21, 2024, between 11:35 AM and 11:45 AM, lacked an installed battery back-up emergency lighting, at the following locations:

a. 11:35 AM, basement, Electrical/Transfer Switch Room;
b. 11:45 AM, exterior, generator enclosure.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of battery back-up emergency lighting.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Observations:
Name: CHAPEL - Component: 02 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain documentation verifying the sensitivity of smoke detectors had been tested within the previous two years, affecting the entire component.

Findings include:

1. Review of documentation on February 21, 2024, between 8:45 AM and 10:45 AM, revealed the facility failed to maintain documentation verifying the sensitivity of smoke detectors had been tested. Facility lacked documentation from the fire alarm company stating it was fully addressable and self-monitoring for sensitivity.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of documentation.

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

1. The Annual Functional Fire inspection, conducted by PYE Barker is scheduled for March 21, 2024. This inspection will include sensitivity of the smoke detectors. Documentation from the testing shall include that the smoke detectors are fully addressable and self-monitoring for sensitivity.
2. The Maintenance Manager shall maintain a file with all inspections' and results, including any repairs that may be required. The annual inspection will be added to the Facilities preventive maintenance schedule for tracking.
3. The Director of Environmental Services shall report the results of all inspections and results at the Facilities QAPI meetings

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: CHAPEL - Component: 02 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide 5-year sprinkler testing documentation, affecting the entire component.

Findings include:

1. Review of documentation on February 21, 2024, between 9:15 AM and 9:17 AM, revealed the facility lacked documentation of the following testing and inspections:

a. 9:15 AM, 5-year, internal pipe inspection;
b. 9:17 AM. 5-year, internal valve inspection.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the facility could not provide documentation of the 5-year internal inspections.

Plan of Correction - To be completed: 03/01/2024

1. The 5 year internal pipe and valve inspection was completed on 4/26 � 4/27/2023. Results available upon request.
2. The Maintenance Manager shall maintain a file with all inspections' and results, including any repairs that may be required. This inspection will be added to the Facilities preventive maintenance schedule for tracking.
3. The Director of Environmental Services shall report the results of all inspections and results at the Facilities QAPI meetings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: CHAPEL - Component: 02 - Tag: 0918

Based on document review and interview, it was determined the facility lacked annual fuel quality analysis for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on February 21, 2024, between 8:45 AM and 10:45 AM, revealed the facility lacked documentation for the annual fuel quality test. A sample was taken on June 7, 2023, but the facility never received the analysis report.

Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of documentation for emergency generator fuel analysis.

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