Nursing Investigation Results -

Pennsylvania Department of Health
DR. ARTHUR CLIFTON MCKINLEY HEALTH CENTER
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
DR. ARTHUR CLIFTON MCKINLEY HEALTH CENTER
Inspection Results For:

There are  32 surveys for this facility. Please select a date to view the survey results.

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DR. ARTHUR CLIFTON MCKINLEY 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 March 30, 2022, it was determined that Dr. Arthur Clifton McKinley Health Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.






 Plan of Correction:


483.73(d) REQUIREMENT EP Training and Testing: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(d), 416.54(d), 418.113(d), 441.184(d), 460.84(d), 482.15(d), 483.73(d), 483.475(d), 484.102(d), 485.68(d), 485.625(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d).

*[For RNCHIs at 403.748, ASCs at 416.54, Hospice at 418.113, PRTFs at 441.184, PACE at 460.84, Hospitals at 482.15, HHAs at 484.102, CORFs at 485.68, CAHs at 486.625, "Organizations" under 485.727, CMHCs at 485.920, OPOs at 486.360, and RHC/FHQs at 491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at 483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at 483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at 483.470(i).

*[For ESRD Facilities at 494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to meet emergency preparedness training and testing requirements.

Findings include:

Document review on March 30, 2022, at 8:55 a.m., revealed the facility failed to provide documentation that the staff had been trained in the last two years on the emergency preparedness program.

Interview with the maintenance director on March 30, 2022, at 8:55 a.m., confirmed the documentation was not available at the time of the survey.




 Plan of Correction - To be completed: 04/21/2022

The facility failed to meet emergency preparedness training and testing requirements.

Education will be provided to staff, including agency staff on the different emergency preparedness components.

A monthly report will be generated and provided to the Director of Environmental Services to ensure new staff and agency staff receive the appropriate emergency preparedness training.

An audits of employees requiring the emergency Preparedness training will be completed 4 (four) weeks and then on a bi-weekly basis for 2 (two) months.

Audit tool and findings will be presented to the Quality Assurance Performance Improvement Committee for recommendations and discussion and outcome reported to the Organizational Safety Committee.

Initial comments:Name: MAIN BUILDING - Component: 02 - Tag: 0000


Facility ID # 421402
Component 02
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 30, 2022, it was determined that Dr. Arthur Clifton McKinley Health Center was not in compliance with the following requirements of the Life Safety Code for an exiting 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 basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General: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.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0211

Based on observation and interview, the facility failed to maintain egress requirements for all emergency exits on the first floor.

Findings include:

Observation on March 30, 2022, between 9:45 a.m. and 12:55 p.m., revealed the emergency egress was obstructed by mattress and wheelchair storage, prohibiting the full use of the area.

Interview with the maintenance director on March 30, 2022, at 12:55 p.m., confirmed the egress route was not fully clear in case of emergency.




 Plan of Correction - To be completed: 04/21/2022

The facility failed to maintain egress requirements for all emergency exists on the first floor.

Staff including agency will be educated on the requirements for ensuring all emergency exit egresses are free from obstruction and the importance of maintaining this clearance.

A monthly report will be generated and provided to the Director of Environmental Services to ensure all new staff and agency staff receive the appropriate training for maintaining the egress clearance.

Staff from maintenance, housekeeping, and laundry will conduct daily walk-around of the areas.

An audits of emergency exit egress clearances will be completed 4 (four) weeks and then on a bi-weekly basis for 2 (two) months. This item will be placed on the on-going quarterly Walk-Through Safety Inspections.

Audit tool and findings will be presented to the Quality Assurance Performance Improvement Committee for recommendations and discussion and outcome reported to the Organizational Safety Committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
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: 02 - Tag: 0345

Based on document review and interview, the facility failed to meet requirements for the fire alarm system.

Findings include:

Document review on March 30, 2022, at 9:03 a.m., revealed the following fire alarm system deficiencies:
A. (9:03 a.m.) The annual report (dated May 7, 2021) noted a smoke detector failed by room 305;
B. (9:03 a.m.) The annual report (dated May 7, 2021) noted a smoke detector by room 301 was no longer recognized by the system;
C. (9:03 a.m.) The facility failed to complete a semi-annual visual inspection.

Interview with the maintenance director on March 30, 2022, at 9:03 a.m., confirmed the facility was unable to provide documentation that the above deficiencies were resolved at the time of the survey.





 Plan of Correction - To be completed: 04/28/2022

The facility failed to meet the requirements for the fire alarm system.

Items identified and addressed are:
Smoke detector failed by room 305; and smoke detector by room 301 was no longer recognized by the system. Both items were previously addressed by the maintenance staff but unfortunately without proper documents. The facility's fire system inspector, Proctor is scheduled to return to the facility on April 29, 2022 to complete the necessary documentation related to these items.

The facility failed to complete a semi-annual visual inspection of the fire alarm system: the semi-annual visual inspection of the smoke detectors was completed but the documentation was not available. A new inspection is scheduled and will be completed by April 15, 2022.

Documentation of the above items and the ongoing semi-annual inspections will be presented to the Quality Assurance Performance Improvement Committee for recommendations and discussion and outcome reported to the Organizational Safety Committee.

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors: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.
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0761

Based on document review and interview, the facility failed to maintain fire and smoke door documentation for all fire and smoke doors throughout the facility.

Findings include:

1. Document review on March 30, 2022, at 8:45 a.m., revealed the facility failed to provide documentation at the time of the survey that the fire door assemblies were inspected and tested in accordance with NFPA 80.

Interview with the maintenance director on March 30, 2022, at 8:45 a.m., confirmed the fire and smoke door documentation was not available at the time of the survey.





 Plan of Correction - To be completed: 04/15/2022

The facility failed to maintain fire and smoke door documentation for all fire and smoke doors throughout the facility.

The fire door assemblies were inspected as required but the documentation was not available for presentation during the survey process.

A new inspection of the fire door assemblies in accordance with NFPA 80 is scheduled for April 15, 2022.

Documentation of the above item and the ongoing door assemblies inspection will be presented to the Quality Assurance Performance Improvement Committee for recommendations and discussion and outcome reported to the Organizational Safety Committee.

NFPA 101 STANDARD Electrical Systems - Wet Procedure Locations:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Electrical Systems - Wet Procedure Locations
Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection.
6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2




Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0913

Based on observation and interview, the facility failed to meet electrical system requirements for one of over fifty rooms.

Findings include:

Observation on March 30, 2022, at 11:13 a.m., revealed the first floor beauty shop had outlets not protected by a ground fault circuit interrupter (GFCI) within six feet of the sink.

Interview with the maintenance director on March 30, 2022, at 11:13 a.m., confirmed the outlet was not protected by a GFCI.





 Plan of Correction - To be completed: 04/03/2022

The facility failed to meet electrical system requirements for one of over fifty rooms.

A hospital grade ground-fault circuit interrupter (GFCI) was installed on April 3, 2022 in the identified room.


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