Nursing Investigation Results -

Pennsylvania Department of Health
ST. JOSEPH'S MANOR (A D/B/A ENTITY OF HRHS)
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. JOSEPH'S MANOR (A D/B/A ENTITY OF HRHS)
Inspection Results For:

There are  55 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.
ST. JOSEPH'S MANOR (A D/B/A ENTITY OF HRHS) - 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 April 14, 2022, at St. Joseph's Manor (a D/b/a Entity Of Hrhs), it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.





 Plan of Correction:


Initial comments:Name: BUILDING 01 (1936 BUILDING) - Component: 01 - Tag: 0000


Facility ID# 451002
Component 01
1936 Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on April 14, 2022, it was determined that St. Joseph's Manor - 1936 Building 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 four-story, Type III (211), protected ordinary construction, with unused attic spaces, which 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 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: BUILDING 01 (1936 BUILDING) - Component: 01 - Tag: 0345

Based on observation review and interview, it was determined the facility failed to maintain the fire alarm system in proper operating condition, affecting the entire component.

Findings Include:

1. Observation on April 14, 2022, at 11:15 am, revealed the facility fire alarm panel was in trouble mode at time of survey.

Interview at the exit conference with the Director of Facilities on April 14, 2022, at 1:45 pm, confirmed the fire alarm panel trouble code.

****************************************

Based on an onsite Revisit conducted on June 14, 2022, the following was determined:

Item 1- Not Completed. The facility fire alarm panel was in trouble mode at the time of survey.

Interview at the exit conference with the Director of Facilities on June 14, 2022, at 1:45 pm, confirmed the fire alarm panel trouble code.




 Plan of Correction - To be completed: 06/17/2022

1a
The fire alarm system is a combined system with the Hospital and the (3) components of the St. Joseph's Manor campus. At the time of the re-inspection, the Fire Alarm contractor was on site performing testing on the system. The system is placed in "TEST" while this is occurring to stop false alarms and unneeded Fire Department responses. While the system is in test mode, that creates a Trouble alarm to show that the system in not in a normal condition. During the entire time the system is in test, there is a technician monitoring the system to insure that any alarms that come in that were not intentionally caused by the testing team are reported for follow-up and the fire department is contacted. The testing has been completed and the system shows everything is normal. The Director of Maintenance will be responsible for insuring the troubles are monitored and the contractors are trained on the alternative fire notification procedures while they have devices off-line.

Initial comments:Name: BUILDING 02 (1976 BUILDING) - Component: 02 - Tag: 0000


Facility ID# 451002
Component 02
1976 Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on April 14, 2022 it was determined that St. Joseph's Manor - 1976 Building was in substantial compliance with the 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 four-story, Type II (222), fire resistive construction, with a basement, which is fully sprinklered.






 Plan of Correction:


Initial comments:Name: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0000


Facility ID# 451002
Component 03
Bridge Link Building

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on April 14, 2022 it was determined that St. Joseph's Manor - Bridge Link Building was in substantial compliance with the 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 four-story, Type II (222), fire resistive construction, with a basement, which is fully sprinklered.






 Plan of Correction:



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