Pennsylvania Department of Health
ST. MARTHA CENTER FOR REHABILITATION & HEALTHCARE
Building Inspection Results

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ST. MARTHA CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

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ST. MARTHA CENTER FOR REHABILITATION & HEALTHCARE - 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 January 24, 2024, at St. Martha Center for Rehabilitation & Healthcare, 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 #457402
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 24, 2024, it was determined that St. Martha Center for Rehabilitation & Healthcare 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 V (000), unprotected wood frame structure, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain the positive latching of doors to hazardous area enclosures, affecting one of ten smoke compartments within the component.

Findings include:

1. Observation on January 24, 2024, at 10:55 AM, revealed the door to the 200 Wing Soiled Linen Storage Room failed to positively latch within the door frame.

Interview with the Facilities Director on January 24, 2024, at 10:55 AM, confirmed the door did not latch within the frame.


2. Observation on January 24, 2024, at 10:58 AM, revealed the door to the 200 Wing Soiled Utility Room failed to positively latch within the door frame.

Interview with the Facilities Director on January 24, 2024, at 10:58 AM, confirmed the door did not latch within the frame.


 Plan of Correction - To be completed: 02/23/2024

K-0321 (E) NFPA 101- Hazardous Areas Enclosure

It is the practice of the facility to have proper latching of doors.
1. Replacement of 200 wing Soiled Linen and Soiled Utility doors latching system was completed on 1/25/2024.
2. All hazardous enclosure doors have been inspected and confirmation of latching has been completed on 1/25/2024.
3. Education is completed with Maintenance staff to confirm proper door operation of doors.
4 Maintenance Director or designee will inspect doors on a monthly basis. This information will then be entered on a log and will be presented to the QAPI meeting X 2 months

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor doors, affecting one of ten smoke compartments within the component.

Findings include:

1. Observation on January 24, 2024, at 11:13 AM, revealed four unprotected penetrations in the door to the Social Services Office, on the Glen Side, where door closing hardware was removed.

Interview with the Facilities Director on January 24, 2024, at 11:13 AM, confirmed the unprotected penetrations of the corridor door.


 Plan of Correction - To be completed: 02/23/2024

K-0363 (E) Corridor- Doors
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
It is the practice of the facility to ensure penetrations are not present in the buildings doors.
1. Doors penetrations were repaired using fire rated materials as per door penetrations guidelines.
2. Doors throughout the facility were checked to ensure no penetrations are present.
3. Education completed with Maintenance staff regarding monitoring doors are free from penetrations.
4. Maintenance Director or designee will check door for penetrations each time a work order is completed for door hardware. That check will be recorded. Update on penetrations will be presented at QAPI X 2 months.

NFPA 101 STANDARD Electrical Systems - Maintenance 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.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to maintain documentation verifying non-hospital grade electrical receptacles within patient care areas, were inspected within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on January 24, 2024, at 9:30 AM, revealed the facility failed to provide documentation verifying non-hospital grade electrical receptacles within patient care areas were inspected since July 2022.

Interview with the Facilities Director on January 24, 2024, at 9:30 AM, confirmed the lack of documentation verifying non-hospital grade electrical receptacles, within patient care areas, were inspected within the previous twelve months.


 Plan of Correction - To be completed: 02/23/2024

K-0914 (E) Maintenance and Testing


It is the practice of the facility to ensure all outlets are inspected annually.
1. All outlets in the building have been inspected for polarity, integrity and tension.
2. Any outlets that needed replacement were replaced/
3. Education completed with Maintenance staff regarding the need to maintain outlets according to regulations has been completed. Audit will be conducted for confirmation annually.
4. Quarterly the Maintenance Director or designee will check outlets throughout the facility to maintain logs of quality of outlet. This information will then be entered on a log and will be presented to the monthly QAPI meeting.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.
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 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of ten smoke compartments within the component.

Findings include:

1. Observation on January 24, 2024, at 10:45 AM, revealed a surge suppressor supplying electrical power to a coffee machine within the ADON Office.

Interview with the Facilities Director on January 24, 2024, at 10:45 AM, confirmed the high draw appliance was plugged into a surge suppressor.


 Plan of Correction - To be completed: 02/23/2024

K-0920 (E) Power Cords and Extensions.

It is the practice of the facility to ensure no power strips or power surge protected outlets supply to heat, cooking or medical equipment.
1. Surge Suppressor supplying power to coffee machine has been removed.
2. All surge protectors supplying power to approved devices have been inspected.
3. Education completed with facility staff regarding the need to maintain surge protectors plugged into proper approved devices only.
4. Maintenance Director or designee will audit electrical devices for safety & proper use of surge protectors throughout the facility quarterly. Audit to be reviewed in QAPI at quarterly.



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