Pennsylvania Department of Health
HOMELAND CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HOMELAND 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 September 24, 2024, at Homeland 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 #600502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on September 24, 2024, at Homeland Center, it was determined there were no deficiencies identified under 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 one-story, Type V(000), unprotected wood frame structure, without a basement, which is fully sprinklered.

Plan of Correction:

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

Facility ID #600502
Component 02
Addition Building

Based on a Medicare/Medicaid Recertification Survey completed on September 24, 2024, it was determined that Homeland 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 (222), fire resistive structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - 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.

Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to positively latch in the frame, in one of seven smoke zones within the component.

Findings include:

1. Observation on September 24, 2024, at 11:40 AM, revealed the basement Boiler Room door, left leaf, failed to close and positively latch in the frame, due to inoperable door coordinator.

Interview at the time of the exit conference with the Director of Emergency Preparedness, Assistant Director of Emergency Preparedness and Compliance Officer on September 24, 2024, at 1:00 PM, confirmed the Boiler Room door failed to close and latch in frame.

Plan of Correction - To be completed: 10/18/2024

Preparation and submission of this Plan of Correction is required by state and federal law. This plan does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.
The observation on September 24th, 2024, revealed basement boiler room door left leaf failed to close and positively latch in frame due to an inoperable door coordinator. Door coordinator was replaced on September 26th, 2024, and is now confirmed to be functioning as designed.
Qualified maintenance staff will perform inspection of all facility door coordinators monthly, documenting the results, to ensure of the proper operation of all door coordinators. This will occur on a permanent basis.
Quality Assurance Performance Improvement (QAPI) Performance Improvement Plan (PIP) will be created to ensure, on an on-going basis, all door coordinators function as designed. This will occur monthly, by inspecting the documentation completed by the maintenance staff, and inspecting ten door coordinators throughout the facility. The results of the plan will be provided at the weekly QAPI meeting. If it is determined the plan is not accomplishing compliance, the plan will be modified to achieve compliance. This will occur on a permanent basis.
The Administrator, Director of Maintenance, Director of Emergency Preparedness/Purchasing, and Director of QAPI will be responsible for on-going compliance.

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