QA Investigation Results

Pennsylvania Department of Health
BARC DEVELOPMENTAL SERVICES INC. CATHERINE
Building Inspection Results

BARC DEVELOPMENTAL SERVICES INC. CATHERINE
Building Inspection Results For:


There are  18 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 December 29, 2020, at BARC Catherine, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.




Plan of Correction:




Initial Comments:
Name - MAIN Component - 01

Facility ID# 28161100
Component 01

Based on a Medicaid Recertification Survey completed on December 29, 2020, it was determined BARC Catherine 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 (111), protected wood frame construction, with a basement and unused attic, which is fully sprinklered.

State plans approved as Impractical.




Plan of Correction:




NFPA 101 STANDARD
Sprinkler System - Installation

Name - MAIN Component - 01
Sprinkler System - Installation
2012 EXISTING (Slow)
In Slow Evacuation Capability facilities where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section 9.7 and shall initiate the fire alarm system in accordance with 9.6, as modified below. The adequacy of the water supply shall be documented.
In Slow Evacuation Capability facilities, an automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One and two Family Dwellings and Manufactured Homes, shall be permitted. Automatic sprinklers shall not be required in closets not exceeding 24 square feet and in bathrooms not exceeding 55 square feet, provided that such spaces are finished with lath and plaster or materials providing a 15-minute thermal barrier.
In Slow Evacuation Capability facilities, where an automatic sprinkler system is in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, automatic sprinklers shall not be required in closets not exceeding 24 square feet and in bathrooms not exceeding 55 square feet, provided that such spaces are finished with lath and plaster or material providing a 15-minute thermal barrier.
In Slow Evacuation Capability facilities, in buildings four or fewer stories above grade plane, systems in accordance with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and including Four Stories in Height, shall be permitted.
Initiation of the fire alarm system shall not be required for existing installations in accordance with 33.2.3.5.6.
Where an automatic sprinkler is installed, attics used for living purposes, storage, or fuel-fired equipment are sprinkler protected. Attics not used for living purposes, storage, or fuel-fired equipment meet one of the following:
1. Protected by heat detection system to activate the fire alarm system according to 9.6.
2. Protected by automatic sprinkler system according to 9.7.
3. Constructed of noncombustible or limited-combustible construction; or
4. Constructed of fire-retardant-treated wood according to NFPA 703.
33.2.3.5.3, 33.2.3.5.3.2 through 33.2.3.5.3.4, 33.2.3.5.3.6

Observations:

Based on document review and interview, it was determined the facility failed to maintain complete automatic sprinkler protection, affecting the entire facility.

Findings Include:

1. Document review on December 29, 2020, between 8:45 a.m. and 11:45 a.m., revealed documentation to confirm testing of the heat detection system, installed inside the non-sprinklered attic, was not available at the time of inspection.

Exit Interview with the House Manager and Director of Maintenance on December 29, 2020, at 12:15 p.m., confirmed the operation of fire alarm system components was not available.





Plan of Correction:

Attic heat detectors were installed on 9/19/20.We are in the process of getting the electrical inspection , which has been delayed to COVID 19 outbreak . Once all needed documentation is received, life/safety will be contacted for a final inspection . Plan were submitted and approve H -20-0942 to add attic heat detectors and to upgrade the fire alarm panel be in compliant with 33.3.3.5.4.2 . Approved upgrades were completed 9/19/20 . Heat detectors will be inspected to be in compliance


NFPA 101 STANDARD
Corridor - Doors

Name - MAIN 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 automatic-closing doors in operable condition, affecting one of one automatic-closing door within the facility.

Findings Include:

1. Observation on December 29, 2020 at 12:08 p.m., revealed the hold-open device, on the automatic-closing door, separating the dining room and kitchen, did not release upon activation of the facility fire alarm system, First Floor.

Exit Interview with the House Manager and Director of Maintenance on December 29, 2020, at 12:15 p.m., confirmed the automatic-closing door required adjustment.





Plan of Correction:

The fire door electronic door release was repaired . The fire door will be tested on the monthly fire drills to ensure proper operation . Maintenance dept. will check as part of monthly preventive maintenance schedule to make sure door operates are in compliant 7.2.1.15.1