Nursing Investigation Results -

Pennsylvania Department of Health
PRESBYTERIAN CENTER FOR CONTINUING CARE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PRESBYTERIAN CENTER FOR CONTINUING CARE
Inspection Results For:
There are 34 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.


PRESBYTERIAN CENTER FOR CONTINUING CARE - 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 September 26, 2019, it was determined that Presbyterian Center For Continuing Care had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

483.73(b)(3) REQUIREMENT Policies for Evac. and Primary/Alt. Comm.:

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.

[(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 annually. At a minimum, the policies and procedures must address the following:]

Safe evacuation from the [facility], 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 RNHCs at §403.748(b)(3) and ASCs at §416.54(b)(2):]
Safe evacuation from the [RNHCI or ASC] which includes the following:
(i) Consideration of care needs of evacuees.
(ii) Staff responsibilities.
(iii) Transportation.
(iv) Identification of evacuation location(s).
(v) Primary and alternate means of communication with external sources of assistance.

* [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):]
Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients.

* [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.

Observations:
Name: - Component: -- - Tag: 0020

Based on document review and interview, it was determined the facility failed to ensure the emergency preparedness plan included transportation documentation for an emergency evacuation of staff and residents, affecting the entire facility.
Findings include:
1. Document review on September 26, 2019, at 8:00 am, revealed there was no documentation available in the emergency preparedness plan that addressed evacuation transportation for residents and staff during an emergency.

Interview at the exit conference with the Director of Engineering and the Assistant Executive Director of Facilities on September 26, 2019 at 2:35 pm, confirmed the documentation was not available.

Plan of Correction - To be completed: 11/25/2019

The Emergency Preparedness Plan includes a copy of the Facility's transportation contract with third-party medical transportation company be used for emergency evacuations. All staff members are re-educated on the Emergency Preparedness Plan to include evacuation transportation. The Emergency Preparedness plan is reviewed quarterly by the Nursing Home Administrator to verify its compliance with life safety regulations. Findings of these reviews are submitted to the Facility's Environment of Care Committee quarterly as part of ongoing quality assurance and performance improvement activity for 2 quarters of sustained compliance and thereafter as necessary.

483.73(c)(8) REQUIREMENT LTC and ICF/IID Sharing Plan with Patients:

[(c) The [LTC facility and ICF/IID] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following:

(8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Observations:
Name: - Component: -- - Tag: 0035

Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives, affecting the entire facility.

Findings include:

1. Document review on September 26, 2019, at 8:00 am, revealed the facility lacked a written Emergency Preparedness plan to include sharing facility emergency preparedness plans and policies with family members and resident representatives.

Interview at the exit conference with the Director of Engineering and the Assistant Executive Director of Facilities on September 26, 2019 at 2:35 pm, confirmed the documentation was not available.

Plan of Correction - To be completed: 11/25/2019

Instructions on how patients, family members and visitors can access the emergency is included in the Facility admission packet. A copy of the Emergency Preparedness Plan is located at the nursing station and remains available upon request. All staff members are educated on family, resident representative and resident requests to access the Emergency Preparedness Plan. Quarterly, the Nursing Home Administrator or designee verifies that the Emergency Preparedness Plan is available for patients and families to review. Quarterly verification of the availability of the emergency plan is documented by the Nursing Home Administrator or designee and submitted to the Facility's Environment of Care Committee quarterly as part of ongoing quality assurance and performance improvement activity for 2 quarters of sustained compliance and thereafter as necessary.

483.73(e) REQUIREMENT Hospital CAH and LTC Emergency Power:

(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)
(e) Emergency and standby power systems. The [LTC facility and the CAH] 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), §485.625(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)
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)
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), 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 document review and interview, it was determined the facility failed to develop an Emergency Preparedness Plan to include a plan to ensure the emergency generator provides continuous power during an emergency, affecting the entire facility.

Findings include:

1. Document review on September 26, 2019, at 8:00 am, revealed the facility's Emergency Preparedness plan lacked a written plan and written agreements or contracts with a secondary fuel supplier for the facility's emergency generator in the event the primary fuel supplier is unavailable during an emergency.

Interview at the exit conference with the Director of Engineering and the Assistant Executive Director of Facilities on September 26, 2019 at 2:35 pm, confirmed the documentation was not available.

Plan of Correction - To be completed: 11/25/2019

The Emergency Preparedness Plan includes a written reference to a secondary fuel supplier for the facility generator. All staff members are re-educated on the secondary fuel supplier for the facility generator as part of the Emergency Preparedness Plan. The Emergency Preparedness Plan is reviewed annually and updated as required. The annual review of the Emergency Preparedness Plan is summarized and findings submitted to the Facility's Environment of Care Committee quarterly as part of ongoing quality assurance and performance improvement activity for 2 quarters of sustained compliance and thereafter as necessary.

Initial comments:Name: MAIN BUILDING 01 (SCHEIE EYE INSTITUTE) - Component: 01 - Tag: 0000

Facility ID# 421102
Component 01
Scheie Eye Institute Building
Continuing Care/Skilled Nursing Unit is located on the fourth floor

Based on a Medicare/Medicaid Recertification Survey completed on September 26, 2019, it was determined that Presbyterian Center For Continuing Care 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 six-story, Type II (222), fire resistive construction, with a penthouse and basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Vertical Openings - Enclosure:

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.

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING 01 (SCHEIE EYE INSTITUTE) - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of vertical shafts, affecting 1 of 8 levels within the facility.

Findings include:

1. Observation on September 26, 2019 at 1:40 pm, revealed, inside 4th floor electrical closet S423, there were two unsealed penetrations in the center shaft wall.

Interview at the exit conference with the Director of Engineering and the Assistant Executive Director of Facilities on September 26, 2019 at 2:35 pm, confirmed the unsealed penetrations.

Plan of Correction - To be completed: 11/25/2019

The penetration identified in S423 was sealed with an approved through penetration Hilti Fire Stop FS1 sealant: UL System No. C-AJ-0070. ANSI/UL 1479. All vertical shafts are inspected quarterly for the absence of unsealed penetrations. When unsealed penetrations are identified, they are sealed with fire rated sealant upon inspection. Data from these quarterly inspections are tabulated by the Director of Maintenance and submitted to the Facility's Environment of Care Committee quarterly as part of ongoing quality assurance and performance improvement activity for 2 quarters of sustained compliance and thereafter as necessary.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 (SCHEIE EYE INSTITUTE) - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure that portable fire extinguishers were inspected, affecting 1 of 8 levels within the facility.

Findings include:

1. Observation made on September 26, 2019, revealed the portable fire extinguisher located inside the 1st floor med gas manifold room was missing a monthly quick-check inspection for August 2019.

Interview at the exit conference with the Director of Engineering and the Assistant Executive Director of Facilities on September 26, 2019 at 2:35 pm, confirmed the the quick-check inspection was not performed.

Plan of Correction - To be completed: 11/25/2019

The fire extinguisher identified in this finding was inspected. All fire extinguishers are inspected monthly by security personnel. Those identified as out of date compliance are inspected by certified life safety inspectors. Security staff members are re-educated in conducting fire extinguisher inspections. Findings from the monthly fire extinguisher inspections are tabulated by the Director of Security and submitted to the Facility's Environment of Care Committee quarterly as part of ongoing quality assurance and performance improvement activity for 2 quarters of sustained compliance and thereafter as necessary.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 (SCHEIE EYE INSTITUTE) - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to maintain electric systems, in wet locations, affecting 1 of 8 levels within the facility.

Findings include:

1. Observation on September 26, 2019, at 1:45 pm, revealed, inside the 4th floor Physical Therapy Room, a hydrocollator was not plugged into a Ground Fault Circuit Interrupter (GFCI) receptacle.

Interview at the exit conference with the Director of Engineering and the Assistant Executive Director of Facilities on September 26, 2019 at 2:35 pm, confirmed the hydrocollator was not plugged into a Ground Fault Circuit Interrupter (GFCI) receptacle.

Plan of Correction - To be completed: 11/25/2019

The hydrocollator identified in this finding was plugged into a GFCI receptacle on September 26, 2019. Electrical systems in wet locations are inspected quarterly to verify that electrical equipment is appropriately connected to GFCI outlets. Maintenance staff members are re-educated on the use of electrical equipment in wet areas and their inspection. Findings of these inspections are tabulated by the Maintenance Director and submitted to the Facility's Environment of Care Committee quarterly as part of ongoing quality assurance and performance improvement activity for 2 quarters of sustained compliance and thereafter as necessary.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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: MAIN BUILDING 01 (SCHEIE EYE INSTITUTE) - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were identified and properly stored, affecting 2 of 8 levels within the facility.

Findings include:

1. Observations made on September 26, 2019, between 12:40 pm and 12:50 pm , revealed unsecured, freestanding medical gas cylinders in the following locations:

a. 12:40 pm, inside the first floor med gas manifold room, there were 7 unsecured, freestanding H-Size carbon dioxide cylinders;
b. 12:50 pm, inside the first floor oxygen storage room, there were 4 unsecured, freestanding H-Size nitrogen cylinders.

Interview at the exit conference with the Director of Engineering and the Assistant Executive Director of Facilities on September 26, 2019 at 2:35 pm, confirmed the gas cylinders were not properly stored in the above named locations.

2. Observation made on September 26, 2019, at 1:05 pm , revealed the door to the 4th floor portable oxygen cylinder storage room did not have the following signage that states:

"CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Interview at the exit conference with the Director of Engineering and the Assistant Executive Director of Facilities on September 26, 2019 at 2:35 pm, confirmed the the door lacked the required signage.

Plan of Correction - To be completed: 11/25/2019

The unsecured carbon dioxide and nitrogen cylinders identified in these findings were secured on September 26, 2019. An "oxygen cylinder storage, no smoking" sign was placed on the door of the oxygen cylinder storage room on September 26, 2019. All respiratory staff members are re-educated on the proper securing of medical gas cylinders. Medical gas cylinder storage areas are inspected quarterly to verify that cylinders are secured safely and that storage areas are marked with appropriate signage noting no smoking. Findings of these inspections are tabulated by the Respiratory Care Department Director and submitted to the Facility's Environment of Care Committee quarterly as part of ongoing quality assurance and performance improvement activity for 2 quarters of sustained compliance and thereafter as necessary.

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