QA Investigation Results

Pennsylvania Department of Health
COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENCE AT UPLAND
Building Inspection Results

COMMUNITIES OF DON GUANELLA AND DIVINE PROVIDENCE AT UPLAND
Building Inspection Results For:


There are  7 surveys for this facility. Please select a date to view the survey results.

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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 Upland, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.





Plan of Correction:




Initial Comments:
Name - DON GUANELLA @ OUR LADY OF CHARITY Component - 01

Facility ID# 24201101
Component 01

Based on a Medicaid Recertification Survey completed on February 04, 2021, it was determined Communities Of Don Guanella And Divine Providence At Upland 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 one story, Type V (000), unprotected wood frame construction, with an attic, which is fully sprinklered.

State plans approved as Impractical.






Plan of Correction:




NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - DON GUANELLA @ OUR LADY OF CHARITY Component - 01
Sprinkler System - Maintenance and Testing
2012 EXISTING (Prompt)
NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, are inspected, tested and maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, are inspected, tested and maintained in accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section 13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20 years (NFPA 25, section 5.3.1.1.1.2).
11. A representative sample of dry pendant sprinklers are tested at 10 years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25, section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system. __________________________________
(Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.)
33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation and interview, it was determined the facility failed to maintain sprinkler system components within a smoke tight assembly, affecting two locations within the facility.

Findings include:

1. Observation on February 4, 2021, between 10:47 a.m. and 10:55 a.m., revealed ceilings were not smoke tight, which could delay the activation of the sprinkler system, in the following locations:

a. 10:47 a.m., Laundry Area, sprinkler escutcheon not tight to the ceiling;
b. 10:55 a.m., Coat Closet by front door, sprinkler escutcheon not tight to the ceiling.

Exit Interview with the Divisional Director of Facilities on February 4, 2021, at 11:00 a.m., confirmed the lack of smoke tight ceilings in the above locations.






Plan of Correction:

1. Correction to sprinkler escutcheon in Laundry area was preformed by contracted vendor to ensure the device was smoke tight to ceiling.
2) Correction to sprinkler escutcheon in Coat Closest area was preformed by contracted vendor to ensure the device was smoke tight to ceiling.
During monthly maintainance walk-thrus this will be noted on checklists for compliance. If an escutcheon is noted not tight to ceiling the vendor will be called to adjust accordingly.
Maintainece check list will be kept on file.




NFPA 101 STANDARD
Utilities - Gas and Electric

Name - DON GUANELLA @ OUR LADY OF CHARITY Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NPFA 70, National Electric Code.
32.2.5.1, 33.2.5.1, 9.1.1, 9.1.2

Observations:

Based on observation and interview, it was determined the facility failed to maintain the installation of electrical components, in accordance with NFPA 70, National Electric Code, Section 210.8(B)5, affecting two locations within the facility.

Findings include:

1. Observation on February 4, 2021, at 10:52 a.m., revealed two non-GFCI outlets located within 6 feet of a sink inside the kitchen.

Exit Interview with the Divisional Director of Facilities on February 4, 2021, at 11:00 a.m., confirmed the non-GFCI outlets mounted within 6 ft of the outside edge of a sink.






Plan of Correction:

The 2 outlets near sink area were replaced with GFCI outlets and are working properly. It was noted that the outlet behind the microwave was faulty causing the breaker to trip. This was also replaced.
During monthly walk-thrus the mainatainance staff will check GFCI outlets to ensure the are working properly. These checks will be noted on checklists and kept on file.