QA Investigation Results

Pennsylvania Department of Health
COMMUNITIES OF DON GUANELLA AND DIVINE P AT 1765 SPROUL ROAD
Building Inspection Results

COMMUNITIES OF DON GUANELLA AND DIVINE P AT 1765 SPROUL ROAD
Building Inspection Results For:


There are  9 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 9, 2022, at Communities Of Don Guanella And Divine Providence at 1765 Sproul Road, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.




Plan of Correction:




Initial Comments:
Name - DON GUANELLA SPROUL RD 3 Component - 01

Facility ID# 24401101
Component 01
Main Building

Based on a Medicaid Recertification Survey completed on February 9, 2022, it was determined Communities of Don Guanella and Divine Providence at 1765 Sproul Road 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, which is Fully sprinklered.

State plans approved as Impractical level of evacuation difficulty.




Plan of Correction:




NFPA 101 STANDARD
Corridor - Doors

Name - DON GUANELLA SPROUL RD 3 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 ensure corridor doors were maintained to resist the passage of smoke, affecting one of one floor.

Findings include:

1. Observation on February 9, 2022, at 9:30 a.m., revealed, resident room 1 corridor door failed to close and latch when tested.

Exit Interview with the Resident Coordinator and Maintenance Supervisor on February 9, 2022, at 10:00 a.m., confirmed the corridor door failed to close and latch.





Plan of Correction:

Resident room #1 had door adjustment made immediately following survey to ensure proper close and latch. All doors will be tested monthly and recorded on preventative maintainance checklist. These checklist are kept on file by facilities Director.