Deficiencies in Life Safety and Carbon Monoxide Alarm Protocols
Penalty
Summary
The facility failed to meet the minimum standards for operation as required by the Department and other state and local agencies. During a review of documentation and observation, it was found that the facility's life safety drawings were incomplete. Specifically, the drawings lacked essential details such as door swings, compartment labeling, fire wall boundaries, smoke wall boundaries, hazardous areas, width of zones, and travel distances. These omissions were confirmed during an exit conference with the Administrator and Director of Maintenance, indicating non-compliance with the requirements for a facility with an active Fire Safety Evaluation System (FSES). Additionally, the facility did not maintain documentation of annual testing and inspection of installed Carbon Monoxide Alarms as per the manufacturer's instructions, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. Furthermore, the facility could not verify that the installed carbon monoxide alarms were audible to on-duty staff. These deficiencies were confirmed during an exit conference with the Administrator and Director of Maintenance, highlighting a failure to adhere to safety protocols designed to protect the health and welfare of residents.
Plan Of Correction
The facility provided current layout and drawings that were to scale accounting for all information (including door swings, compartment labeling, fire wall boundaries, smoke wall boundaries, hazardous areas, width of zones and travel distances). The facility to install Carbon Monoxide detectors, in the required designated areas, with linking alarm devices in manned locations. The facility will audit all current detectors and remove devices in areas not needed. The facility to ensure preventative maintenance and auditing of the carbon monoxide devices, as per manufacturers guidance. The facility to provided education to maintenance on Act 48 PA Carbon Monoxide Requirements. Maintenance to report findings to QAPI for 3 months.