Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on February 20, 2024, at St. Joseph's Center Swoyersville, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 45581100
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on February 20, 2024, it was determined that St. Joseph's Center Swoyersville 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, that is fully sprinklered.
State plans approved as Impractical.
Plan of Correction:
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - MAIN BUILDING 01 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 maintain one hazardous area enclosure, affecting one of one floor.
Findings include:
1. Observation on February 20, 2024, at 11:03 a.m., revealed the basement door lacked a self-closing device.
Exit interview with the Facilities Manager on February 20, 2024, between 11:30 a.m., and 11:40 a.m., confirmed the hazardous area enclosure deficiency.
Plan of Correction:The basement door will be evaluated and a closing device will be installed .
Device will be tested om a monthly basis.
NFPA 101 STANDARD
Sprinkler System - Installation
Name - MAIN BUILDING 01 Component - 01
Sprinkler System - Installation
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 Section 9.6, as
modified below. The adequacy of the water supply shall be documented.
In Prompt Evacuation 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 Prompt 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 Prompt 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 by July 5, 2019. 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, 33.2.3.5.3.1, 33.2.3.5.3.3, 33.2.3.5.3.4, 33.2.3.5.3.6, 33.2.3.5.7
Observations:
Based on observation and interview, it was determined the facility failed to install and maintain the automatic sprinkler system in two instances, affecting one of one floor.
Findings include:
1. Observation on February 20, 2024, between 10:58 a.m., and 11:14 a.m., revealed the following:
a. 10:58 a.m., the hall closet lacked automatic sprinkler protection.
b. 11:14 a.m., the facility lacked a five year, internal valve, and five year, internal pipe inspection.
Exit interview with the Facilities Manager on February 20, 2024, between 11:30 a.m., and 11:40 a.m., confirmed the automatic sprinkler system deficiencies.
Plan of Correction:Classic fire protection will be contacted to set up and schedule installation of sprinkler head in the hall closet.
Vendor will also be contracted to complete internal pipe inspection.
NFPA 101 STANDARD
Corridor - Doors
Name - MAIN BUILDING 01 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 one corridor opening, affecting one of one floor.
Findings include:
1. Observation on February 20, 2024, at 10:55 a.m., revealed the bedroom door, located closest to the office, required adjustment to fully latch.
Exit interview with the Facilities Manager on February 20, 2024, between 11:30 a.m., and 11:40 a.m., confirmed the corridor opening deficiency.
Plan of Correction:Bedroom door has been evaluated and in house maintenance staff will do repairs to insure proper latching .
door will be tested on minthly basis
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