Facility Fails to Obtain Required Approvals and Update Policies
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 Division of Safety Inspection in writing about the approved PA DOH Stamped Drawing Index of H-22-0230, indicating when construction started and when it 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 portable, accurate floor plans 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. This deficiency was also confirmed during the exit interview with the facility's administrative staff.
Plan Of Correction
1. The initial notification in writing of the generator had been completed. The addition of the Docking Station on 12/17/24 was just completed the day before the annual Life Safety survey, so we had not had the time yet to write a notification. Upon the exit interview, there was confusion on our part that the notification needed to be done in writing. That is being submitted today, 1/8/25. 2. The Carbon Monoxide alarm evacuation policy plan has been attained and staffing education will be completed by Friday, January 10th, 2025. 3. Maintenance will update the floor plan to include the items that are needed to make the floor plan correct. The following will be added: a. Smoke Barrier Walls (outside wall to outside wall) b. Fire Barrier Walls (2-hour walls) c. Horizontal Exits d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan. e. Required Exits should be clearly noted; and f. Shaft Walls This will be completed by January 15th, 2025.