Pennsylvania Department of Health
RITTENHOUSE POST ACUTE
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RITTENHOUSE POST ACUTE
Inspection Results For:

There are  15 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.
RITTENHOUSE POST ACUTE - 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 19, 2025, it was determined that Rittenhouse Post Acute had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.




 Plan of Correction:


403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually: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.
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.
Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, it was determined the facility failed develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually, for one of one plan.

Findings include:

Document review on May 19, 2025, at 10:35 a.m., revealed the facility failed conduct the required annual review of its Emergency Preparedness Plan.

Exit Interview with the Plant Manager and Maintenance Director on May 19, 2025, at 11:50 a.m., confirmed the missing annual update of its Emergency Preparedness Plan.






 Plan of Correction - To be completed: 07/07/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."



The facility has an updated Emergency Preparedness Plan.

The Maintenance Director will be educated on the importance of having an updated emergency plan.

The NHA/designee will review the Emergency Preparedness Binder to ensure the contents are current and up to date, once per week for 2 weeks and then monthly for 3 months. The results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations, including any indication of the need for further audits based on the audit findings.

403.748(b)(2), 416.54(b)(1), 418.113(b)(6)(ii) and (v), 441.184(b)(2), 482.15(b)(2), 483.475(b)(2), 483.73(b)(2), 485.542(b)(2), 485.625(b)(2), 485.920(b)(1), 486.360(b)(1), 494.62(b)(1) STANDARD Procedures for Tracking of Staff and Patients: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.
§403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

*[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.

*[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.

*[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

*[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.
Observations:
Name: - Component: -- - Tag: 0018

Based on document review and interview, the facility failed to maintain emergency Preparedness guidelines for one of one Emergency Preparedness Plan.

Findings include:,.

Document review on May 19, 2025, at 9:30 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes tracking the location of on-duty staff and residents during an emergency or disaster event.

Exit Interview with the Plant Manager and Maintenance Director on May 19, 2025, at 11:50 a.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 07/07/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

The facility has an updated Emergency Preparedness Plan that includes tracking the location of on-duty staff and residents during an emergency or disaster event.

The Maintenance Director will be educated on the importance of having an updated Emergency Preparedness Plan that includes tracking the location of on-duty staff and residents during an emergency or disaster event.

The NHA/designee will review the Emergency Preparedness Binder to ensure the contents are current and up to date, including tracking and location of on-duty staff and residents during an emergency or disaster event, once per week for 2 weeks and then monthly for 3 months. The results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations, including any indication of the need for further audits based on the audit findings.

Initial comments:Name: RELOCATION - SNF 5TH FLOOR PENN MED RITTENHOUSE - Component: 10 - Tag: 0000


Facility ID# 421102
Component 10
Penn Medicine-Rittenhouse
Continuing Care/Skilled Nursing Unit

Based on a Medicare/Medicaid Recertification Survey completed on May 19, 2025, it was determined that Rittenhouse Post Acute was not in compliance with the following requirements of the Life Safety Code for an 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 six-story, Type II (222), fire resistive building, with a penthouse and basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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 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: RELOCATION - SNF 5TH FLOOR PENN MED RITTENHOUSE - Component: 10 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system, affecting two of eight levels.

Findings include:

Document review on May 19, 2025, at 8:30 a.m., revealed the April 4, 2025, fire alarm inspection report listed multiple batteries as deficient, this condition remained uncorrected at time of survey.

Exit Interview with the Plant Manager and Maintenance Director on May 19, 2025, at 11:50 a.m., confirmed the fire alarm deficiency.




 Plan of Correction - To be completed: 07/07/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."

The batteries have been replaced per the fire inspection report dated 4/4/2025.

The NHA or designee will complete an audit of the most recent fire inspection report to confirm if any batteries are deficient.

The NHA or designee will educate the Maintenance Director on the importance of making sure that deficient batteries are replaced timely.

The NHA/designee will randomly review the fire inspection reports once per week for 2 weeks and then monthly for 3 months to confirm that any deficient batteries have been
replaced, the results of the audits will be submitted to the Quality Assurance Performance Improvement Committee for review and recommendations, including any indication of the need for further audits based on the audit findings.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: RELOCATION - SNF 5TH FLOOR PENN MED RITTENHOUSE - Component: 10 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were secured and separated from combustible materials, affecting one of eight levels.

Findings include:

Observation on May 19, 2025, at 10:50 a.m., revealed, on the fifth floor, in supply room, combustible plastic wrap was laying atop the oxygen cylinders.

Exit Interview with the Plant Manager and Maintenance Director on May 19, 2025, at 11:50 a.m., confirmed the oxygen storage deficiency.




 Plan of Correction - To be completed: 07/07/2025

"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."


The combustible plastic wrap has been removed from the room containing oxygen cylinders.

The Maintenance Director was educated on the importance of making sure there are no combustible materials lying on oxygen cylinders.

The NHA/Designee will conduct an audit to ensure that there are no combustible materials are being stored with oxygen cylinders.

The NHA/Designee will randomly audit the oxygen storage 2x per week for 2 weeks and then monthly x3 to ensure that there are no combustible materials stored with oxygen cylinders.


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