Pennsylvania Department of Health
 HEALTH CENTER AT THE HILL AT WHITEMARSH, THE
Building Inspection Results

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HEALTH CENTER AT THE HILL AT WHITEMARSH, THE
Inspection Results For:

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HEALTH CENTER AT THE HILL AT WHITEMARSH, THE - 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 6, 2024, at The Health Center at The Hill at Whitemarsh, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0000


Facility ID# 17900201
Component 01
Long-Term Skilled Unit (Village D)

Based on a Medicare/Medicaid Recertification Survey completed on March 6, 2024, it was determined that The Health Center at The Hill at Whitemarsh was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 three-story, Type II (111), protected non-combustible building, with a basement, that is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies - Construction Type: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.
Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
Observations:
Name: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0133

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of common walls, affecting one of four levels.

Findings include:

Observation on March 6, 2024, revealed fire rated common wall deficiencies, in the following locations:

a. 11:15 a.m., on the second floor, above fire doors separating Skilled/Independent, unsealed penetration around electrical wires.
b. 10:41 a.m., on the second floor, fire doors separating Skilled/Independent failed to latch when tested.

Exit interview with the Maintenance Director on March 6, 2024, at 11:45 a.m., confirmed the common wall deficiencies.




 Plan of Correction - To be completed: 03/15/2024

Sealed all electrical pipe penetrations above Fire Doors in Building D side.
Installed Access panel on Building E independent side of Fire Doors so both sides of wall penetrations are sealed. Fire caulk: 3M Fire Barrier Sealant CP 25WB+. Per fire safety guidelines.

An audit will be conducted to ensure no penetration is present. All audits will be monitored by the Facilities Director or designee and will be brought to QAPI for review.

Fire doors from part a - the Left door between Building D & E latch was adjusted so doors close properly and latch.

Weekly rounds will be conducted to ensure doors latch properly x4 Monthly, and then bimonthly x2.

The Facilities Director or designee will monitor and submit audits to QAPI for review monthly x3 to ensure compliance.


NFPA 101 STANDARD Building Construction Type and Height: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.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to maintain the fire resistance rating of the building construction, affecting one of four levels.

Findings Include:

Observation on March 6, 2024, at 10:30 a.m., revealed, on the first floor, in the corridor by fire pump room, an unknown expanding foam product used to fill ceiling/floor assembly penetrations.

Exit interview with the Maintenance Director on March 6, 2024, at 11:45 a.m., confirmed the prohibited foam substance.





 Plan of Correction - To be completed: 03/15/2024

The ceiling above the Fire Pump room door in corridor 1st floor Building D was removed and was replaced with Fire caulk: 3M Fire Barrier Sealant CP 25WB+. Per fire safety guidelines.

An audit will be conducted to ensure all penetrations are sealed with the approved fire caulk. All audits will be monitored by The Facilities Director or designee and will be brought to QAPI for review.

The Facilities Director or designee will monitor and submit audits to QAPI for review monthly x3 to ensure compliance.


NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0225

Based on observation and interview, it was determined that the facility failed to maintain stair towers, affecting one of four levels.

Findings include:

Observation on March 6, 2024, at 11:20 a.m. revealed an electric scooter was stored on the landing, on the second floor, D stair tower.

Exit interview with the Maintenance Director on March 6, 2024, at 11:45 a.m., confirmed the storage within the stair tower.




 Plan of Correction - To be completed: 03/15/2024

The electric scooter left under the steps in building D-2nd floor stair tower was removed immediately.

Contractors were in-serviced on keeping stairwells free and clear of any/all items.

Daily rounds will be conducted to ensure stairwells are free and clear of any/ all items.

The Facilities Director or designee will monitor and submit audits to QAPI for review monthly x3 to ensure compliance.


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: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0321

Based on observation and interview, it was determined that the facility failed to maintain hazardous areas, affecting one of four levels.

Findings include:

Observation on March 6, 2024, at 10:15 a.m., revealed on the first floor electrical transformer room had combustible storage within the room.

Exit interview with the Maintenance Director on March 6, 2024, at 11:45 a.m., confirmed the storage in the hazardous electrical room.




 Plan of Correction - To be completed: 03/15/2024

The electrical transformer room on the 1st floor was cleared out, and all combustible materials have been removed.

Staff and contractors have been in-serviced on the importance of not storing combustible material in any electrical transformer room.

Weekly rounds will be conducted to ensure electrical transformers are clear of all combustible material x4 monthly, then bimonthly x2.

The Facilities Director or designee will monitor and submit audits to QAPI for review monthly x3 to ensure compliance.


NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
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: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

Document review on March 6, 2024, at 9:00 a.m., revealed the March 11, 2023, sprinkler inspection noted the following deficiency: "needs new rebuild kit for dry system" , evidence of corrective action was not available at time of survey.

Exit interview with the Maintenance Director on March 6, 2024, at 11:45 a.m., confirmed the sprinkler system deficiency.




 Plan of Correction - To be completed: 03/15/2024

The sprinkler deficiency on the Dry System was repaired by Johnson Controls on 4-14-2023. Documentation is located in the Maintenance Manager's office.

At the time of inspection, the document was not available for inspection review.

NFPA 101 STANDARD Electrical Systems - 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.
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: LONG-TERM SKILLED UNIT (VILLAGE D) - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested at patient bed locations within the facility.

Findings include:

Document review on March 6, 2024, at 9:00 a.m., revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not recorded as required for non-hospital grade receptacles at intervals not exceeding 12 months. Receptacle testing should include the following:

a. visual inspection of physical integrity.
b. correct polarity of the hot and neutral connections.
c. retention force of the grounding blade (except locking-type receptacles) shall not be less than 4 oz.

Exit interview with the Maintenance Director on March 6, 2024, at 11:45 a.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 03/15/2024

The annual receptacle testing in the Mather House Skilled Unit for calendar year 2023 was not completed in a timely manner.

The 2024 Annual receptacle testing was completed from 3-6-2024 through 3-24-24.

Work orders have been generated to ensure receptacles are tested every 12 months.

An automated system has been initiated to alert the Maintenance Manager prior to the testing dates to ensure NFPA requirements are being met.

Facilities Director or designee will monitor and submit audits to QAPI for review monthly x3 to ensure compliance.



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