Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 21, 2024, at Communities Of Don Guanella And Divine Providence At Frankford, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - DON GUANELLA HOMES AT FRANKFORD DUFFY HALL Component - 01
Facility ID #24311101
Component 01
Duffy House
Based on a Medicaid Recertification Survey completed on May 21, 2024, it was determined that the Communities Of Don Guanella And Divine Providence At Frankford 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 building, with an attic, that is fully sprinklered.
State Plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Corridor - Doors
Name - DON GUANELLA HOMES AT FRANKFORD DUFFY HALL Component - 01
Corridor - Doors
Doors shall meet all of the following requirements:
1. Doors shall be provided with latches or other mechanisms suitable for keeping the door closed.
2. No doors shall be arranged to prevent the occupant from closing the door.
3. Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 in buildings other than those protected throughout by an approved automatic sprinkler system in accordance with 33.2.3.5.
Door assemblies with leaves required to swing in the direction of egress travel are inspected and tested annually per 7.2.1.15.
33.2.3.6.4, 33.7.7
Observations:
Based on observation and interview, it was determined the facility failed to maintain corridor doors without obstructions, affecting one of one floor.
Findings include:
Observation on May 21, 2024, at 8:45 a.m., revealed all corridor doors leading to resident rooms utilized rubber door wedges to keep doors propped open.
Exit Interview on May 21, 2024, at 9:45 a.m. with the Adminstrator and Director of Maintenance, on May 21, 2024, confirmed the use of unauthorized hold-open devices.
Plan of Correction:Immediately following inspection on 5/21/24 house Manager(HM) was retrained that use of door wedges/stops are prohibited from use.
The HM then began all staff training to this policy. The Residential Coordinator along with facility manintainance staff will completed monthly environmental audits to ensure compliance. Any non-compliance seen through audits will be brought to the Administrator's attention. The Administrator will direct corrective action as needed.
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