Pennsylvania Department of Health
PENNKNOLL VILLAGE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PENNKNOLL VILLAGE - 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 February 21, 2024, it was determined that Pennknoll Village had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(b)(1), 418.113(b)(6)(iii), 441.184(b)(1), 482.15(b)(1), 483.475(b)(1), 483.73(b)(1), 485.542(b)(1), 485.625(b)(1) STANDARD Subsistence Needs for 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)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1)

[(b) Policies and procedures. [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 every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:

(1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical supplies
(ii) Alternate sources of energy to maintain the following:
(A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(B) Emergency lighting.
(C) Fire detection, extinguishing, and alarm systems.
(D) Sewage and waste disposal.

*[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following:
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.

Observations:
Name: - Component: -- - Tag: 0015

Based on a review of the Emergency Preparedness (EP) Plan, it was determined the facilities policies and procedures failed to address all requirements of subsistence needs for staff and patients.

Findings include:

1. Interview and documentation review of the facility EP plan on February 21, 2024, at 11:50 a.m., revealed section (D) sewage and waste disposal requirements were not addressed in the EP Plan.

Interview with the Facility Administrator and the Maintenance Director on February 21, 2024, at 1:00 p.m., confirmed the listed deficiency in the Emergency Preparedness (EP) Plan.

Plan of Correction - To be completed: 03/12/2024

1. The facility's Federal Emergency Plan (Fed EP) will be updated with documentation of policies and procedures for the disposal of sewage and waste in the event of a loss of the normal utility.
2. There is only one required Fed EP, therefore no additional reviews were needed.
3. The Executive Director educated the Maintenance Director and Director of Clinical Services on the importance of 42 CFR 483.73- Subsistence Needs for Staff and Patients specific to properly maintaining Fed EP documentation for the disposal of sewage and waste in the event of a loss of the normal utility, and will continue to monitor in accordance with the standard.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 680602
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 21, 2024, it was determined that Pennknoll Village 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 one-story, Type II (000), unprotected, non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on February 21, 2024, at 9:14 a.m., revealed the facility failed to maintain storage below the eighteen inch horizontal sprinkler plain in the activities janitor/storage room.

Interview with the Facility Administrator and the Maintenance Director on February 21, 2024, at 1:00 p.m., confirmed the listed automatic sprinkler system deficiency.

Plan of Correction - To be completed: 03/12/2024

1. The improper storage noted in the activity's janitor/storage room was moved below the eighteen-inch horizontal sprinkler plain.
2. Additional storage rooms were reviewed for maintaining storage below the eighteen-inch horizontal sprinkler plain.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of National Fire Protection Agency (NFPA) 101 Sprinkler System- Maintenance and Testing specific to properly maintaining storage below the eighteen-inch horizontal sprinkler plain, and will continue to monitor in accordance with the NFPA.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in two instances, affecting two of seven smoke compartments.

Findings include:

1. Observation on February 21, 2024, revealed the following corridor door deficiencies:

a) 9:09 a.m., the door to resident room 511 had a large gap at the top when closed and latched in its frame, leaving the door unable to resist the passage of smoke;
b) 9:27 a.m., the door to resident room 202 was unable to close and latch when tested, leaving the door unable to resist the passage of smoke.

Interview with the Facility Administrator and the Maintenance Director on February 21, 2024, at 1:00 p.m., confirmed the listed corridor door deficiencies.

Plan of Correction - To be completed: 03/12/2024

1. The door to resident room 511, noted to have a gap at the top when closed and latched, will be made smoke tight. The door to resident room 202 will be repaired to properly close and latch.
2. Additional resident room doors will be reviewed for smoke tightness and proper closing and latching.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of National Fire Protection Agency (NFPA) 101 Corridor- Doors specific to maintaining resident room doors to be smoke tight and properly close and latch, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of seven smoke compartments.

Findings include:

1. Observation above the ceiling at the 100 hallway smoke barrier doors on February 21, 2024, at 9:36 a.m., revealed the facility used an unapproved sealant (spray foam) to seal the smoke barrier wall (room 113 side of the wall).

Interview with the Facility Administrator and the Maintenance Director on February 21, 2024, at 1:00 p.m., confirmed the listed smoke barrier wall deficiency.

Plan of Correction - To be completed: 03/12/2024

1. The improperly sealed smoke barrier wall, noted above the ceiling at the 100 hallway smoke barrier doors, will be properly sealed with a listed and rated fire stopping material.
2. Additional smoke barrier walls will be reviewed for being properly sealed with listed and rated fire stopping materials.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of National Fire protection Agency (NFPA) 101 Subdivision of Building Spaces- Smoke Barrier Construction specific to properly maintaining smoke barrier walls with listed and rated fire stopping materials, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in two instances, affecting two of seven smoke compartments.

Findings include:

1. Observation on February 21, 2024, revealed the following electrical wiring and systems deficiencies:

a) 8:57 a.m., there was a refrigerator that was plugged into a power strip, that was plugged into a second power strip (daisy chained together), in the scheduling office;
b) 9:24 a.m., there was a microwave and a refrigerator plugged into a power strip in the social service office.

Interview with the Facility Administrator and the Maintenance Director on February 21, 2024, at 1:00 p.m., confirmed the listed electrical wiring systems and equipment deficiencies.

Plan of Correction - To be completed: 03/12/2024

1. The power strips noted to be in improper use in the scheduling and social service offices were removed on-site.
2. Additional office areas were reviewed for the improper power strips.
3. The Executive Director/ designee will educate the Maintenance Director on the importance of National Fire Protection Agency (NFPA) 101 Electrical Equipment- Power Cords and Extension Cords specific to the improper use of power strips in office areas, and will continue to monitor in accordance with NFPA standards.
4. Any findings will be reported to the monthly Quality Assurance Performance Improvement Committee for further review.

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