QA Investigation Results

Pennsylvania Department of Health
COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENC AT FAIRHILL
Building Inspection Results

COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENC AT FAIRHILL
Building Inspection Results For:


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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on February 4, 2021, at Communities Of Don Guanella And Divine Providence At Fairhill, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.





Plan of Correction:




Initial Comments:
Name - FAIRHILL Component - 01

Facility ID# 24131101
Component 01
Fairhill

Based on a Medicaid Recertification Survey completed on February 4, 2021, it was determined that Communities Of Don Guanella And Divine Providence At Fairhill was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).

This is a two story, Type V (000), unprotected wood frame construction, with a basement, which is fully sprinklered.

State plans approved as Impractical.







Plan of Correction:




NFPA 101 STANDARD
Means of Egress - General

Name - FAIRHILL Component - 01
Means of Escape - General
2012 EXISTING
Designated means of escape shall be continuously maintained clear of obstructions and impediments to full instant use in the case of fire or emergency.
33.2.2

Observations:

Based on observation and interview, it was determined the facility failed to maintain the means of egress clear of obstructions, affecting one exit within the facility.

Findings include:

1. Observation on February 4, 2021, at 9:06 a.m., revealed the path to the public way from the kitchen exit door had not been cleared of snow.

Exit Interview with the Divisional Director of Facilities on February 4, 2021, at 9:15 a.m., confirmed the pathway had not been cleared of snow.






Plan of Correction:

Snow was immediately removed from kitchen exit door. Director of Facilities spoke with house manager on site regarding the importance of clearly all exits of snow and ice.
Director of operations re-trained house manager and all facility staff on the importance of timely snow and ice removal. These trainings will be kept of file at house. A notation was also documented in house communication book. The Director of Operations will monitor future compliance.