Pennsylvania Department of Health
 SIMPSON HOUSE INC
Building Inspection Results

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SIMPSON HOUSE INC
Inspection Results For:

There are  47 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SIMPSON HOUSE INC - 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 July 15, 2024, at Simpson House, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


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


Facility ID # 192802
Component 01
Old Flanagan Building

Based on a Medicare/Medicaid Recertification Survey completed on July 15, 2024, it was determined that Simpson House - Old Flanagan Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 four-story, Type II (000), unprotected, non-combustible building, with a basement, that 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 01 - Component: 01 - Tag: 0161

Based on observation, document review, and interview, the facility failed to maintain the fire-resistance rating for the building construction, affecting the entire facility.

Findings include:

Observation and document review on July 15, 2024, between 8:30 a.m. and 12:00 p.m., revealed the building height exceeded the limit for a four-story, Type II (000), unprotected, noncombustible construction.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed the story height exceeded the limit for this type of construction.




 Plan of Correction - To be completed: 08/05/2024

1: The FSES has been updated on 11/14/2023 by Lenhardt Rodgers Architecture and a copy has been forwarded to Life Safety as well as DOH Harrisburg and the Local Field office in Norristown.

2: FSES will continue to be updated yearly.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to ensure automatic sprinkler components were maintained, affecting one sprinkler system.

Findings Include:

Document review on July 15, 2024, at 9:30 a.m., revealed current 5-year internal sprinkler inspection was not available for review at time of survey.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 08/05/2024

1- Cintas completed the inspection of the internal sprinkler system.


2- Date completed - July 22 through July 24,2024.

3-The Facility's Director/designee will ensure that the 5-year internal sprinkler inspection will be completed.

4-The internal sprinkler inspection results will be discussed in the next monthly Quality Assurance meetings.


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of five levels.

Findings include:

Observation on July 15, 2024, at 12:15 p.m., revealed an unsealed open penetration, on the ground floor, above smoke doors by room #3.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed the penetration.




 Plan of Correction - To be completed: 08/05/2024

1: The penetration on the ground floor, above the smoke doors by room #3 was sealed with 3M Firestop system W-L-0031. Product 3M Fire Barrier Sealant CP 25WB+.

2: The plan of correction date is 07/15/2024

3: The Director of Facilities/ Designee will perform random monthly audits to check for unsealed penetrations throughout the facility.

4- The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to ensure doors in smoke barrier walls were maintained to resist the passage of smoke, affecting one of five levels.

Findings include:

Observation on July 15, 2024, at 11:10 a.m., revealed, on the second floor, smoke doors by room 202 failed to close smoke tight when tested.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed the doors failed to close smoke tight.




 Plan of Correction - To be completed: 08/05/2024

1: The smoke doors in Flanagan 2nd floor near room 202 were adjusted tightly to maintain the passage of smoke.

2: The plan of correction date is 07/15/2024

3: The Director of Facilities/ Designee will perform random monthly audits to ensure smoke doors are tightly sealed throughout the facility.

4- The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste: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.
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 01 - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting one generator.

Findings include:

Document review on May 14, 2024, at 9:30 a.m., revealed annual fuel quality test results for the emergency generators diesel fuel were not available for review at time of survey.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 08/05/2024

1: The annual fuel quality test results were completed by Gen Serve on 07/19/2024. A copy of the results has been obtained for facility records.

2: The plan of correction date is 08/05/2024

3: The Director of Facilities/ Designee will schedule annual fuel quality tests for the facility.

4- The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.
Initial comments:Name: BUILDING 02 (PHYSICAL THERAPY) - Component: 02 - Tag: 0000


Facility ID # 192802
Component 02
Physical Therapy, Multi-purpose/Meeting Room

Based on a Medicare/Medicaid Recertification Survey completed on July 15, 2024, at Simpson House - Physical Therapy, Multi-purpose/Meeting Room, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing Nursing 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 two-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.






 Plan of Correction:


Initial comments:Name: BUILDING 03 (NEW FLANAGAN BUILDING) - Component: 03 - Tag: 0000


Facility ID # 192802
Component 03
New Flanagan Building

Based on a Medicare/Medicaid Recertification Survey completed on July 15, 2024, it was determined that Simpson House - New Flanagan Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 four-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies: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.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: BUILDING 03 (NEW FLANAGAN BUILDING) - Component: 03 - Tag: 0131

Based on observation and interview, the facility failed to maintain the fire resistance rating for common wall separations, affecting two of five levels.

Findings include:

Observation on July 15, 2024, at 11:40 a.m., revealed unsealed penetrations in the common fire wall separating the old and new components, in the following locations:

a. 11:30 a.m., on the second floor, above fire doors- open hole.
b. 12:00 p.m., on the ground floor, at Pantry, around a pipe.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed the penetrations.





 Plan of Correction - To be completed: 08/05/2024

A:
1: The penetration on the second floor, above the fire doors was sealed with 3M Firestop system W-L-0031. Product 3M Fire Barrier Sealant CP 25WB+.

2: The plan of correction date is
07/16/2024

3: The Director of Facilities/ Designee will perform random monthly audits to check for unsealed penetrations throughout the facility.

4- The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.

B:

1: The penetration on the ground floor pantry around the pipe was sealed with
3M Firestop system C-AJ-1044 Product 3M Fire Barrier Sealant CP 25WB+.

2: The plan of correction date is
07/16/2024

3: The Director of Facilities/ Designee will perform random monthly audits to check for unsealed penetrations throughout the facility.

4- The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.





NFPA 101 STANDARD Illumination of Means of Egress: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.
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Name: BUILDING 03 (NEW FLANAGAN BUILDING) - Component: 03 - Tag: 0281

Based on observation and interview, it was determined that the facility failed to ensure continuous illumination of means of egress on one of five levels.

Findings include:

Observation on July 15, 2024, at 11:45 a.m., revealed on the first floor, Flanagan #1 stair tower had a light out.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed the burned-out bulb.




 Plan of Correction - To be completed: 08/30/2024

1- The light bulb in Flanagan #1 stair tower was replaced.

2- Date completed - 07/15/2024

3The Facility's Director/designee will audit the stair towers for properly functioning light bulbs weekly times 4 weeks, then bi-weekly for 4 weeks, then monthly for 1 month to ensure sustained compliance.

4-The audit results will be discussed during the monthly Quality Assurance meetings.

5-The Quality Assurance committee will determine if continued auditing is necessary based on achieving three consecutive months of compliance.
NFPA 101 STANDARD Electrical Systems - Other: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.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: BUILDING 03 (NEW FLANAGAN BUILDING) - Component: 03 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of five levels.

Findings include:

Observation on July 15, 2024, at 11:40 a.m., revealed on the first floor, in room 127, a light switch was missing its cover plate, exposing the inner wiring.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.





 Plan of Correction - To be completed: 08/30/2024

1- The cover plate for the light switch in in the Flanagan building room 127 was replaced.

2- Date completed - 07/15/2024

3-The Facility's Director/designee will audit resident rooms and common areas for cover plates over light switches to ensure no exposed wires weekly times 4 weeks, then bi-weekly for 4 weeks, then monthly for 1 month to ensure sustained compliance.

4-The audit results will be discussed during the monthly Quality Assurance meetings.

5-The Quality Assurance committee will determine if continued auditing is necessary based on achieving three consecutive months of compliance.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) 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 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.
Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Name: BUILDING 03 (NEW FLANAGAN BUILDING) - Component: 03 - Tag: 0916

Based on observation and interview, it was determined the facility failed to maintain alarm annunciation for the Essential Electrical System, affecting the entire building.

Findings Include:

Observation on July 15, 2024, at 11:50 a.m., revealed the generator remote annunciator panel is not in a continuously monitored location, in a vacated nurse station on the ground floor.

Exit Interview with the Administrator and Maintenance Director on July 15, 2024, at 12:45 p.m., confirmed emergency generator components were not monitored.





 Plan of Correction - To be completed: 08/30/2024

1- The Annunciator panel was relocated in the Flanagan building on the ground floor across from the nursing station in the occupied part of the unit.

2- Date completed - 07/17/2024

3-The Facility's Director/designee will monitor the Annunciator panel weekly times 4 weeks, then bi-weekly for 4 weeks, then monthly for 1 month to ensure sustained compliance.

4-The audit results will be discussed during the monthly Quality Assurance meetings.

5-The Quality Assurance committee will determine if continued auditing is necessary based on achieving three consecutive months of compliance.

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