Pennsylvania Department of Health
POCOPSON HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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POCOPSON HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on March 6, 2024, at Pocopson Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #162002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 5 and March 6, 2024, it was determined that Pocopson Home was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a five-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component.

Findings include:

1. Observation on March 5, 2024, at 11:00 AM, revealed the facility is a five-story, Type II (000), unprotected noncombustible structure, with a basement. This type of construction is not permitted to be greater than two stories in height, with sprinkler protection.

Interview with the Building and Grounds Director on March 5, 2024, at 11:00 AM, confirmed the construction type is not allowed in health care.

Plan of Correction - To be completed: 03/18/2024

Architect prepared construction drawings submitted and approved by the DOH. The work is scheduled to be completed during 2024 - 2025.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain the fire resistance of exit stairtower enclosures, affecting two of seventeen smoke compartments within the component.

Findings include:

1. Observation on March 5, 2024, at 1:24 PM, revealed the stairtower door located in 2 West Staff Development, next to Room 216, did not positively latch within the door frame.

Interview with the Building and Grounds Director on March 5, 2024, at 1:24 PM, confirmed the stairtower door did not latch within the frame.

2. Observation on March 5, 2024, at 1:40 PM, revealed an unprotected penetration of the 2nd floor stairtower, by Pantry 244, above the suspended ceiling, around two red fire alarm wires.

Interview with the Building and Grounds Director on March 5, 2024, at 1:40 PM, confirmed the unprotected penetration of the stairtower enclosure.

Plan of Correction - To be completed: 03/18/2024

1. The hardware on the stair tower door located in 2 West Staff Development, next to room 216 was removed, lubricated and reinstalled to positively latch within the door frame.

2. The unprotected penetration of the 2nd floor stair tower, by pantry 244, above the suspended ceiling, around two red fire alarm wires, in the Jones Building, has been sealed using an approved through penetration fire stop system.

The Maintenance department will maintain the rating of all stair towers and will inspect for penetrations and door latching within door frames during their weekly maintenance rounds. Audit results will be reported to the Quality Improvement/Infection Control Committee.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

NFPA 101 STANDARD Utilities - Gas and Electric:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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 NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to maintain components of electrical hardware, affecting one of seventeen smoke compartments within the component.

Findings include:

1. Observation on March 6, 2024, at 9:11 AM, revealed an electrical junction box without a cover plate correctly installed located above the suspended ceiling, within the corridor by the Storage Room, across from Resident Room 305.

Interview with the Building and Grounds Director on March 6, 2024, at 9:11 AM, confirmed the electrical junction box did not have a cover plate correctly installed.

Plan of Correction - To be completed: 03/18/2024

A cover plate has been correctly installed to the electrical junction box above the suspended ceiling, within the corridor by the Storage Room, across from Resident Room 305.

The Maintenance department staff will inspect all electrical junction boxes for the correct installation of covers during their weekly maintenance rounds. Audit results will be reported to the Quality Improvement/Infection Control Committee.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide documentation verifying weekly visual inspections of the emergency generator had been performed within the previous twelve months, affecting the entire component.

Findings include:

1. Review of documentation on March 5, 2024, at 1:10 PM, revealed the facility failed to provide documentation verifying a visual inspection of the emergency generator had occurred between 11/28/2023 and 12/12/2024.

Interview with the Building and Grounds Director on March 5, 2024, at 1:10 PM, confirmed the lack of documentation verifying weekly visual inspections of the emergency generator had occurred within the previous twelve months.

Plan of Correction - To be completed: 03/18/2024

Visual inspection of the emergency generator will be completed weekly as scheduled. The maintenance department will maintain weekly documentation to ensure compliance with these weekly inspections.

The Maintenance Department Director has educated staff to ensure weekly visual generator inspection and documentation. The Maintenance Department staff will audit this documentation during weekly inspections. Audit results will be reported to the Quality Improvement/Infection Control Committee.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of seventeen smoke compartments within the component.

Findings include:

1. Observation on March 6, 2024, at 8:52 AM, revealed a surge suppressor supplying electrical power to a personal space heater within the Admissions Office.

Interview with the Building and Grounds Director on March 6, 2024, at 8:52 AM, confirmed the high draw appliance was plugged into a surge suppressor.

Plan of Correction - To be completed: 03/18/2024

The surge suppressor supplying electrical power to a personal space heater within the Admissions Office is removed.

The Maintenance Department Director has educated staff to no longer use suppressors to supply power to high draw appliances. The Maintenance Department staff will inspect all electrical receptacles throughout the facility on a monthly basis.

Audit results will be reported to the Quality Improvement/Infection Control Committee.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

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