Deficiencies in Emergency Power Generator Approval and Policy Updates
Penalty
Summary
The facility failed to obtain the required Pennsylvania Department of Health Final Occupancy Inspection approval for the replacement of the facility's emergency power generator and other essential electrical system components. This deficiency was identified during an observation, interview, and documentation review conducted on December 18, 2024. The facility did not notify the Norristown Department of Safety Inspection in writing about the approved PA DOH Stamped Drawing Index of H-22-0230, indicating when construction started and was completed. This lack of notification was confirmed during an exit interview with the Administrator, Administrator in training, and Maintenance Director. Additionally, the facility did not update its policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. The document review revealed the absence of a carbon monoxide alarm evacuation policy plan and associated staff in-service training. Furthermore, the facility failed to provide accurate portable floor plans, which are required for the Life Safety Code Survey. The provided floor plans lacked indications of smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. These deficiencies were confirmed during an exit interview with the facility's administration and maintenance staff.
Plan Of Correction
We notified Norristown Department of DSI on 1/30/2025. We needed to gather more documentation for DSI. This documentation will be completely acquired and submitted by 2/28/25.