QA Investigation Results

Pennsylvania Department of Health
COMMUNITIES OF DON GUANELLA AND DIVINE PROVI AT MEETINGHOUSE
Building Inspection Results

COMMUNITIES OF DON GUANELLA AND DIVINE PROVI AT MEETINGHOUSE
Building Inspection Results For:


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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on December 30, 2020, at Communities Of Don Guanella And Divine Providence at Meetinghouse, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.




Plan of Correction:




Initial Comments:
Name - MEETINGHOUSE ROAD Component - 01

Facility ID # 24151101
Component 01

Based on a Medicaid Recertification Survey completed on December 30, 2020, it was determined Communities Of Don Guanella And Divine Providence at Meetinghouse, 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 three-story, Type V (000), unprotected wood frame construction, with a basement and unoccupied attic, which is fully sprinklered.

State plans approved as Impractical.




Plan of Correction:




NFPA 101 STANDARD
Hazardous Areas - Enclosure

Name - MEETINGHOUSE ROAD Component - 01
Hazardous Areas - Enclosure
2012 EXISTING (Prompt)
Any hazardous area that is on the same floor as, and is in or abut, a primary means of escape or a sleeping room shall be protected by one of the following means:
1. Protection shall be an enclosure with a fire resistance rating of not less than 1 hour, with a self-closing or automatic closing fire door in accordance with 7.2.1.8 that has a fire protection rating of not less than 3/4 hour.
2. Protection shall be automatic sprinkler protection, in accordance with 33.2.3.5, and a smoke partition, in accordance with 8.4 located between the hazardous area and the sleeping area or primary escape route. Any doors in such separation shall be self-closing or automatic closing in accordance with 7.2.1.8.
Other hazardous areas shall be protected in accordance with 33.2.3.2.5 by one of the following:
1. An enclosure having a fire resistance rating of not less than 1/2 hour, with a self-closing or automatic-closing door in accordance with 7.2.1.8 that is equivalent to not less than a 13/4 inch (4.4 cm) thick, solid-bonded wood core construction.
2. Automatic sprinkler protection in accordance with 33.2.3.5, regardless of enclosure.
Areas with approved, properly installed and maintained furnaces and heating equipment, and cooking and laundry facilities are not classified as hazardous areas solely on basis of such equipment.
Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 33.2.3.2.
33.2.2.2.4, 33.2.3.2, 33.2.3.2.5

Observations:

Based on observation and interview, it was determined the facility failed to ensure combustible material in storage rooms was properly stored, affecting one of three stories within the facility.
Findings include:
1. Observation on December 30, 2020, at 9:15 a.m., revealed, inside the Second Floor large storage room, above the kitchen, there were three "E" sized portable oxygen cylinders stored next to a rack of combustible disposable diapers and bed pads.
Interview with the Director of Facilities and Director of Maintenance at the exit conference on December 30, 2020, at 9:35 a.m., confirmed there were portable oxygen cylinders stored next to combustible material.




Plan of Correction:

- 'E' tanks and disposable diapers and pads were removed
- signage was placed at top of stairs alerting staff that this area is not meant for any storage
- All staff was trained that this area can not be used for storage. Training sheets will be kept on file.
- Re-training also occurred for proper storage of "E' tanks, location only in nurses room and must be in a proper holder at all times
-House Manager will be responsible for daily environmental checks
-Facilities staff will complete monthly maintainance walk-thrus and will record on monthly checklist to ensure compliance.