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Home My WebLink AboutELE2007-02834 ANNUAL SURVEY 9-14-07.TIF�y � M North Carolina Department of Health and Human Division of Health Service Regulation Michael F. Easley, Governor Dempsey Benton, Secretary Construction Section 2705 Mail Service Center. Raleigh, North C September 14, 2007 4("4 3 (.0 Lori Crouch, Administrator Professional Family Care, Inc 906 3rd Street SE Conover NC 28613 RE: FC - Annual Survey FID #1944445 Professional Family Care 906 3rd. Street SE Conover (Catawba County) Dear Ms. Crouch: SEP 19 2007 S ILDING SERVICES Wills m L. Warren, Chief A ll , ti one: 919 - 855 -3893 .,,): v^ �� Fax: 919 - 733 -6592 f ill- G h� Thank you for the cooperation and courtesies extended during the recent Division of Health Service Regulation (DHSR) - Construction Section Annual Survey of your facility on September 07, 2007 As a result of this survey, deficiencies were cited which will require an acceptable Plan of Correction. The deficiencies cited are listed on the enclosed Statement of Deficiencies. Your Plan of Correction should indicate a specific action to be taken to correct and prevent recurrence of the deficiency, together with an estimated date of completion. Please note the following governing regulations: Corrective action must begin immediately and be completed within a reasonable time. Any completion date greater than 30 days from the date of letter requires written justification from the Provider. Please type or print clearly your corrective action on the enclosed Statement of Deficiencies. SIGN, DATE AND RETURN the Plan of Correction to DHSR - Construction Section by 10/14/2007 Failure to return this signed Plan of Correction within the time period could jeopardize the status of your license. This office will schedule a follow -up inspection after the last completion date indicated on the signed Plan of Correction. Prior to making any changes to your facility you will need to verify with the local Building Official whether or not a permit is needed to make the changes on the enclosed Statement of Deficiencies. Please do not hesitate to call us if you have questions or if we can be of further assistance. Sincerely, Anthony BrirAn Facility Engineering Specialist DHSR - Construction Section cc: Adult Care Licensure Section - with attachment County Building Inspection Department - with attachment Catawba County DSS - with attachment �� Location: 701 Barbour Drive .Dorothea Dix Hospital Campus .Raleigh, N.C. 27603 An Equal Opportunity / Affirmative Action Employer PRINTED: 09/14/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A BUILDING 01 FCLO18026 B. WING 09/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL FAMILY CARE, INC 906 3RD STREET SE CONOVER, NC 28613 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS - REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) C 000 Initial Comments C 000 Report of Survey by Anthony Brinson and Ed Miller Based on Information gathered from DHSR Master Facility File and LTI databases this facility was first licensed or submitted for licensure as Professional Family Care, Inc. on March 02, 1994, it is currently licensed as Professional Family Care a six bed (all- ambulatory) Family Care Home. Based on this information we are requiring the facility to meet the 1993 Rules for the Licensing of Family Care Homes and the applicable portions of the 2005 Regulations for Family Care Homes. It is also required to meet the 1993 Edition of the North Carolina State Building Code Volume VII - Residential. An annual inspection was conducted on September 07, 2007 by the DHSR- Construction Section with the following deficiencies. C 101 Existing Licensed -No Less than '71 Rules C 101 SECTION .0300 - THE BUILDING 10A NCAC 13G .0301 APPLICATION OF PHYSICAL PLANT REQUIREMENTS The physical plant requirements for each family care home shall be applied as follows: (2) Except where otherwise specified, existing licensed homes or portions of existing licensed homes shall meet licensure and code requirements in effect at the time of construction, change in service or bed count, addition, renovation or alteration; however, in no case shall the requirements for any licensed home, where no addition or renovation has been made, be less than those requirements found in the 1971 "Minimum and Desired Standards and Regulations" for "Family Care Homes ", copies of Division of Health Service Regulation TITLE (X6) DATE LABORATORY DIRECTOR'S OR PROVIDERISUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 8899 B93121 If continuation sheet 1 of 6 PRINTED: 09/14/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 01 FCLO18026 B. WING 09/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL FAMILY CARE, INC 906 3RD STREET SE CONOVER, NC 28613 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS - REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) C 101 Continued From page 1 C 101 which are available at the Division of Health Service Regulation - Construction Section, 701 Barbour Drive, Raleigh, North Carolina 27603 at no cost; This Rule is not met as evidenced by: 1.) Per Section R -217 of the North Carolina State Building Code the Interior Finish of the home is required to meet at a minimum a flame - spread classification of not greater than 200 or a Class C Finish. The wood veneer paneling in the office doesn't meet this requirement. Provide documentation that all wood veneer paneling has been treated with a flame retardant paint or additive or it will need to be treated again. 2.) Per Section R -210.2 of the North Carolina State Building Code every sleeping room shall have at least one openable window or exterior door approved for emergency egress. The units must be operable without the use of a key or tool to a full clear opening. It was found in the staff bedroom that the bedroom window was inoperable, either correct the window to open freely or remove the dresser from in front of the side exit door to the outside. C 174 Building Equipment Maintained Safe, Operating C 174 SECTION .0300 - THE BUILDING 10A NCAC 13G.0317 BUILDING SERVICE EQUIPMENT (a) The building and all fire safety, electrical, mechanical, and plumbing equipment in a family care home shall be maintained in a safe and operating condition. 0) This Rule shall apply to new and existing family care homes. Division of Health Service Regulation STATE FORM 8899 B93121 If continuation sheet 2 of 6 PRINTED: 09/14/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 01 FCLO18026 B. WING 09/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL FAMILY CARE, INC 906 3RD STREET SE CONOVER, NC 28613 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS - REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) C 174 Continued From page 2 C 174 This Rule is not met as evidenced by: 1.) The receptacle located on the front porch at the ceiling isn't GFCI protected as required, Per NEC - Section 210 -8. Have a licensed electrician replace the receptacle with a Ground Fault Circuit Interrupted (GFCI) receptacle and also provide a weather proof cover. 2.) The N.C.S. E. C. Article 110.12 (c) Integrity of Electrical Equipment and Connections: Internal parts of electrical equipment, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives etc. It was noted that the receptacle in the staff bathroom has been painted over, removing the paint from the receptacle covers will not meet the intent of the rule. The Receptacle in Question Must be Replaced , have a licensed electrician replace the damaged device and forward to our office a copy of receipt(s) when done and verify no other receptacles have been painted over. 3.) It was observed from the attic that where the exhaust duct for the hood penetrates the roof the wood is damaged in this area (splintered /decayed) have a licensed contractor or carpenter or roofer make any necessary repairs as needed and provide verification to our office. 4.) Have a Licensed Electrician or your HVAC vendor provide a weatherproof cover or junction box for the low voltage wiring located outside the HVAC unit. C 113 Kitchen C 113 T10: 42C Division of Health Service Regulation STATE FORM 8899 B93121 If continuation sheet 3 of 6 PRINTED: 09/14/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 01 FCLO18026 B WING 09/0712007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL FAMILY CARE, INC 906 3RD STREET SE CONOVER, NC 28613 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS - REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) C 113 Continued From page 3 C 113 .2204 KITCHEN (a) The kitchen must be large enough to provide for the preparation and preservation of food and the washing of dishes. (b) The cooking unit must be mechanically ventilated to the outside. (c) The kitchen floor must have non - slippery water - resistant covering. This Rule is not met as evidenced by: 1.) The hood is vented to the outside as required, but it seems there is some minor blockage, when in operation it was blowing air down instead of pulling up. Clean the duct and hood assembly to maintain proper ventilation. C 137 Outside Entrances /Exits -Ramps C 137 T10: 42C .2209 OUTSIDE ENTRANCES AND EXITS (c) At least two outside entrances /exits for the residents' floor level must be at ground level or accessible by ramp with a 1 inch rise for each 12 inches of length of the ramp. If there are only two entrances /exits, the entrances /exits must be as remote from each other as reasonably possible. This Rule is not met as evidenced by: 1.) At the front entrance there is a area between the porch and the ramp resulting in a 1" change of elevation or dip constituting a potential trip hazard. Provide a permanent transition between the two to eliminate the hazard where the porch and ramp meet at a required slope ratio of 1" rise for each 12" of length. 2.) The ramp at the rear is not compliant with the rule requirements of construction rate of 1" rise for each 12" of length (you have 1" rise for 6" of length). Current Licensure rule 10A NCAC 13G Division of Health Service Regulation STATE FORM 8899 693121 If continuation sheet 4 of 6 PRINTED: 09/14/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 01 FCLO18026 B. WING 09/0712007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL FAMILY CARE, INC 906 3RD STREET SE CONOVER, NC 28613 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS - REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) C 137 Continued From page 4 C 137 .0312 (c) only requires a ramp at your principal entrance /exit which for your purposes is the front entry. Based on this fact at this time we wont require you to make any structural changes to the rear ramp unless we receive a complaint from clients, family, staff or visitors. C 140 Outside Entrances /Exits - Handrails C 140 T10: 42C .2209 OUTSIDE ENTRANCES AND EXITS (f) All steps, porches, stoops and ramps must be provided with handrails and guardrails. This Rule is not met as evidenced by: 1.) Add a support column in the central portion of the railing for additional support for the handrail at the rear exit. C 156 Fire Safety- Smoke, Heat Detectors C 156 T10: 42C .2213 FIRE SAFETY EQUIPMENT (b) The home must provide automatic, single station U.L. listed smoke (ionization) detectors in locations as determined by the Division of Health Service Regulation and U.L. listed heat detectors in the attic and basement. These detectors must be directly wired to the house current. This Rule is not met as evidenced by: 1.) At the time of inspection it was observed that the smoke detectors located in the hallway outside the sleeping rooms were not wired to the house current but were single station battery operated devices. Amendment 210 -71 from the 1993 North Carolina State Electrical Code Division of Health Service Regulation STATE FORM 6890 893121 If continuation sheet 5 of 6 PRINTED: 09/14/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 01 B. WING FCLO18026 09/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 906 3RD STREET SE PROFESSIONAL FAMILY CARE, INC CONOVER, NC 28613 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS - REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) C 156 Continued From page 5 C 156 requires at a minimum one 120 volt permanently connected automatic smoke detector outside each sleeping area at or near the ceiling level. Have a licensed electrician pull the necessary permits and provide smoke detector(s) in the hallway as required. The new detector(s) should be located so as no device is greater than 11 feet of any bedroom door. 2.) Provide verification of the location of the sounding device for the attic heat detectors, the heat detectors must be connected to a dedicated sounding device located in either the attic or living area. Have a licensed electrician install the sounding device and verify the existing heat detectors and the new sounding device are operable. Division of Health Service Regulation STATE FORM B B93121 If continuation sheet 6 of 6