HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the common wall separation in two of the three common walls within this component..

Findings include:

1. Observation made on July 29, 2013 at 9:30 am, revealed the common wall separating the New Addition building from the Main Building by patient room 255, had an unsealed penetration by wiring above the common wall door.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the unsealed penetration of the common wall.

2. Observation made on July 29, 2013 at 10:00 am, revealed the common wall inside the small dining room into the kitchen dining room door was dragging on the floor.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above common wall door requires adjustment to positively latch.

Based on observation and interview, it was determined that the facility failed to ensure that common maintain a fire resistive rating free of unsealed penetrations in the one of four fire walls within this component.

Findings include:

1. Observation made on July 29, 2013, at 9:48 am, revealed that on the N1 unit above the common wall ceiling near room 233, there was a soffit that had a gap that was not sealed where the soffit and the common wall mee.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the gap in the common wall separation.


2. Observation made on July 29, 2013, at 9:30 am, revealed at the common separating the New Addition Building from the Main Building by patient room 255, had an unsealed penetration by wiring above the common wall door.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the unsealed penetration of the common wall.

Based on observation and interview, it was determined that the facility failed to ensure corridor doors positively latch into their frames in two of three smoke zones within this component..

Findings include:

1. Observation made on July 29, 2013 between 10:10 am and 11:00 am, revealed that following corridor doors failed to latch.

a. 10:10 am, corridor door to the kids dining room (needed excessive force to fully close and latch).
b. 10:45 am, room 150 (needed excessive force to fully close and latch).
c. 11:00 am, room 140 (failed to latch).

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above corridor doors failed to positively latch into their frames.

Based on observation and interview, it was determined the facility failed to maintain the corridor doors to positively latching into their frames in one of four smoke zones.

Findings include:

1. Observation on July 29, 2013 at 10:30 am, revealed the door of room 5 did not have a latching mechanism and could not positively latch into the door frame.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the corridor door requires adjustment.


2. Observation on July 29 2013, at 10:45 am, revealed the corridor door of the isolation suite failed to stay latched when pressure was applied.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the corridor door requires adjustment.

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors resist the passage of smoke, are free of damage and impediments to closing, and positively latch when tested in four of four smoke zones within this component.

Findings include:

1. Observations made on July 29, 2013, between 10:01 am, and 11:16 am, revealed corridor doors that failed to positively latch when tested in the following locations:
a. 10:01 am, N 4 unit patient room 103, latching hardware missing.
b. 10:03 am, N 4 unit patient room 10, latching hardware missing.
c. 10:34 am, N 2 unit patient room 136, latching hardware missing.
d. 10:40 am, N 2 unit Quiet room, door failed to positively latch.
e. 10:43 am, N 2 unit patient room 154, latching hardware missing.
f. 11:05 am, N 1 unit patient room 232, latching hardware missing.
g. 11:13 am, N 1 unit Quiet room, latch hardware stuck in recessed position.
h. 11:16 am, N 1 unit patient room 202, latching hardware missing.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the improper and unauthorized use of power strips, extension cords and outlet multipliers in the above named locations.

2. Observation made on July 29, 2013, at 11:15 am, revealed that on the N 1 unit, the door to patient room 200 was starting to delaminate at the bottom half of the door.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the door was damaged.


3. Observation made on July 29, 2013, at 11:17 am, revealed that in the N 1 unit, the door to the Social Services office door was propped open by a chair.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed and the subsequent correction of the deficiency during the time of the survey.


4. Observation made on July 29, 2013, at 11:19 am, revealed that on the N 1 unit, the door to patient room 206 had a gap greater than one half inch between the door and the top of the frame, which would not resist the passage of smoke.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the door was not smoke tight.


5. Observation made on July 29, 2013, at 10:26 am, revealed that on the N 3 unit Quiet room, the corridor door had four circular holes that penetrate the door near the handle where aprevious hardware had been removed.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the holes in the door.

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier walls maintain a fire resistive rating free of unsealed penetrations in two of two smoke zones within this component.

Findings Include:

Observation made on July 2913, at 9:40 am, revealed at the smoke barrier wall at the N3 unit by room 153, there was a red fire alarm wire that was sealed with a grey latex material. The facility could not produce documentation verifying the fire rating at the time of the survey.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed there was a smoke barrier penetration.

Based on observation and interview, it was determined that the facility failed to maintain hazardous areas within a smoke tight separation, in sprinklered locations, in one of three smoke zones within this component.

Findings include:

Observation made on July 29, 2013 at 9:50 am, revealed that in the basement the boiler room door had its latch receiver taped over, preventing the door from latching.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above hazardous area door failed to latch.

Based on observation and interview, it was determined the facility failed to maintain clear acces to the exit egress in two of four smoke zones.

Findings include:

1. Observation on July 29, 2013 between 10:00 am and 10:25 am, revealed table and chairs were placed in the exit access at the following locations:

a. 10:00 am, Pod B, Day Room, a table and two wheeled office chairs were unattended in the corridor between the patio and the lobby access doors.
b. 10:25 am, Pod C, Day Room, a table and wheeled office chair were in the corridor between the linen storage closet and the lobby access doors, but were attended by a staff member.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the table and chairs were in the exit access.

Based on documentation review and interview, it was determined that the facility failed to ensure that fire drills are being conducted during varied times within this component.

Findings Include:

Document review made on July 29, 2013, between 1:00 pm, and 2:30 pm, revealed that the fire drills for the main building were not being conducted during varying times for the second and third shifts, as follows:

Second shift:
February 27, 2013, 4:02 pm.
May 29, 2013, 3:55 pm,
August 14, 2012, 4:00 pm.
November 30, 2012, 3:55 pm.

Third shift:
March 28, 2013, 5:56 am,
June 27, 2013, 6:01 am,
September 27, 2012, 5:59 am,
December 27, 2012, 6:00 am.

The fire drills were being conducted towards the end of the month and close to the end of the hour.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the the fire drills were not being conducted during varied times.

Based on observation and interview, it was determined the facility failed to maintain fire alarm notification devices in an operable condition in one of four smoke zones.

Findings include:

Observation on July 29, 2013 at 10:40 am, revealed that the heat detector in the Arts & Crafts Area was hanging below the ceiling level, leaving a gap between the detector and the ceiling.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the heat detector was not in a smoke tight assembly.

Based on observation and interview, it was determined that the facility failed to ensure that buildings, which are classified as fully sprinklered, had maintained sprinkler protection in all required areas in one of three smoke zones within this component..

Findings include:

Observation made on July 29, 2013 at 9:55 am, revealed that the basement level electrical room lacked sprinkler coverage. There were two branch lines in the room capped off.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the basement electrical room lacked sprinkler coverage.

Based on observation and interview, it was determined that the facility failed to ensure that complete automatic sprinkler protection is provided in buildings classified as fully sprinklered and there are no obstructions to activation of sprinkler heads in five smoke zones within this component.

Findings Include:

1. Observation made on July 29, 2013, at 10:12 am, revealed that in the N4 unit quiet room, the small sink room lacks sprinkler protection.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the sink room lacked sprinkler protection.


2. Observation made on July 29, 2013, at 11:30 am, revealed the Attic space lacks sprinkler protection. The attic area runs the full length of the building and houses mechanical air handling ductworks and IT equipment racks.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the attic space lacks sprinkler protection.


3. Observations made on July 29, 2013, between 10:20 am, and 10;28 am, revealed sprinkler heads with buildup of dirt and debris, which could delay the activation of the sprinkler in the following locations:

10:20 am, N3 unit corridor by nurse station and staff lounge 124.
10:28 am, N3 unit laundry room.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the build up of dirt and debris in the above named locations.


4. Observation made on July 29, 2013, at 8:21 am, revealed that in the front entrance vestibule the sprinkler head was missing an escutcheon plate and was not smoke tight.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the missing escutcheon plate for the sprinkler head.


5. Observation made on July 29, 2013, at 10:00 am, revealed that in the N4 unit day room closet, the sprinkler head had become detached from the monolithic ceiling assembly and was not smoke tight.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the sprinkler head was detached from the monolithic ceiling.


6. Observations made on July 29, 2013, between 9:36 am, and 10:53 am, revealed missing and broken ceiling tiles and monolithic ceiling assemblies that were not smoke tight, which could delay activation of sprinkler heads in the following locations:

a. 9:36 am, Housekeeping closet 136, hole in monolithic ceiling.
b. 10:11 am, N4 unit Quiet room, gap around the sprinkler head.
c. 10:36 am, N2 unit day room by the television set, pipe penetrating the ceiling tile and the hole around the pipe is not smoke tight. This condition was seen in other day rooms.
d. 10:53 am, N2 unit clean linen room 220, ceiling tiles had being removed.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the non- smoke tight ceiling assemblies in the above named locations.


7. Observation made on July 29, 2013, at 11:14 am, revealed that inside the N1 unit mechanical room, the drop down ladder attic access door was in the open position, exposing the mechanical space to the attic. The mechanical room is also being used to store large linen carts that were preventing the access door from closing. The linen carts where filled to the point that bags of linen were within eighteen inches of the sprinkler heads.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the open access door and obstructions to the sprinkler heads.

Based on observation and interview, it was determined that the facility failed to maintain sprinkler components in reliable operating condition and kept free of obstructions in three of three smoke zones within this component.

Findings include:

1. Observation made on July 29, 2013 at 9:47 am, revealed in the basement level boiler room, the following items were noted:

a. One sprinkler head was covered with plastic
b. One sprinkler head had spray fire proofing applied. This sprinkler head must be replaced.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above location had obstructed sprinkler heads.

2. Observation made on July 29, 2013 between 10:52 am and 11:35 am, revealed that the following locations had solid shower curtains that would obstruct the water development pattern of the sprinkler heads:

a. 10:52 am, room 147.
b. 10:55 am, room 145.
c. 11:25 am, the entire N5 wing with the exception of rooms 124, 125 and 126.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above locations had solid curtains obstructing the sprinkler heads.

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers readily accessible at all times in one of three smoke zones within this component.

Findings include:

Observation made on July 29, 2013 at 9:45 am, revealed that in the basement mechanical room near the rear exit, the fire extinguisher was blocked from access.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above fire extinguisher was blocked from access.

28 Pa. Code § 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. § 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal,State and local laws and regulations.

Findings include:

Observation on July 29, 2013 at 9:40 am, revealed the facility is undergoing renovations of the patient pods in order to install ligature resistant hardware and fixtures. The facility has not submitted a narration of the renovations or plans for review by the Department of Health.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the facility had not submitted documentation of renovations for review.

Based on observation and interview, it was determined that the facility failed to prevent the unauthorized use of electrical devices and did not remove temporary wiring after use in two of three smoke zones within this component.

Findings include:

1. Observation made on July 29, 2013 between 10:25 am and 11:40 am, revealed the unauthorized or improper use of electrical devices at the following locations:

a. 10:25 am, room 166 group therapy office (extension cord in use).
b. 10:30 am, room 166 group therapy office (microwave powered by a powerstrip powered by a extension cord).
c. 11:05 am, N5 Chart room (coffee maker powered by a extension cord).

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed at the above locations there was unauthorized or improper use of electrical devices found.

2. Observation made on July 29, 2013 at 11:05 am, revealed inside the N5 housekeeping closet above the drop ceiling, there was temporary lighting still in place.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above location had temporary lighting in place.

Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of electrical devices in one of four smoke zones.

Findings include:

1. Observation on July 29, 2013 between 9:10 am and 9:30 am, revealed extension cords were being used at the following locations:

a. 9:10 am, Utilization Review Office.
b. 9:30 am, Doctor's Office.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed there were extension cords being used.


2. Observation on July 29, 2013 between 9:12 and 9:25 am, revealed surge protectors were being used to power appliances at the following locations:

a. 9:12 am, Utilization Review Office.
b. 9:25 am, Doctor's Office.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the surge protectors were being used in an unauthorized manner.

Based on observation and interview, it was determined that the facility failed to prevent the unauthorized use of electrical devices and protect electrical wiring in in four of four smoke zones within this component.

Findings include:

1. Observations made on July 29, 2013, between 8:56 am, and 11:10 am, revealed the unauthorized and improper use of extension cords, powerstrips, and outlet multipliers in the following locations:
a. 8: 56 am, ground floor conference room, refrigerator, coffee maker and water cooler plugged into a powerstrip that had damaged outlets.
b. 9:28 am, Chief Executive Officer office, extension cord plugged into a powerstrip that was powering a refrigerator.
c. 9:33 am, Utilization office 138, refrigerator plugged into a powerstrip.
d. 10:08 am, N4 unit Doctors office, brown extension cord in use plugged into a powerstrip and a microwave oven plugged into a powerstrip.
e. 10:37 am, N2 unit Medications room, small refrigerator plugged into an colored extension cord.
f. 11:10 am, N1 Social Worker office, middle desk area, six plug outlet multiplier in use.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the unauthorized use of electrical devices.


2. Observation made on July 29, 2013, at 10:55 am, revealed inside the N 2 unit Housekeeping closet, there was an electrical outlet that was missing a protective face plate cover.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the missing electrical outlet face plate.

3. Observation made on July 29, 2013, at 11:47 am, revealed that inside the exterior accessed generator room, that houses the older generator set, there was an open junction box at the rear of the building next to the wall mounted electrical meter.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the open junction box.

4. Observation made on July 29, 2013, at 11:30 am, revealed that in the attic space above the N1 unit access steps, there was yellow contractor 's temporary wiring lying on top of the ceiling tile assembly.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the temporary wiring in the attic space.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the common wall separation in two of the three common walls within this component..

Findings include:

1. Observation made on July 29, 2013 at 9:30 am, revealed the common wall separating the New Addition building from the Main Building by patient room 255, had an unsealed penetration by wiring above the common wall door.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the unsealed penetration of the common wall.

2. Observation made on July 29, 2013 at 10:00 am, revealed the common wall inside the small dining room into the kitchen dining room door was dragging on the floor.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above common wall door requires adjustment to positively latch.

Based on observation and interview, it was determined that the facility failed to ensure that common maintain a fire resistive rating free of unsealed penetrations in the one of four fire walls within this component.

Findings include:

1. Observation made on July 29, 2013, at 9:48 am, revealed that on the N1 unit above the common wall ceiling near room 233, there was a soffit that had a gap that was not sealed where the soffit and the common wall mee.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the gap in the common wall separation.


2. Observation made on July 29, 2013, at 9:30 am, revealed at the common separating the New Addition Building from the Main Building by patient room 255, had an unsealed penetration by wiring above the common wall door.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the unsealed penetration of the common wall.

Based on observation and interview, it was determined that the facility failed to ensure corridor doors positively latch into their frames in two of three smoke zones within this component..

Findings include:

1. Observation made on July 29, 2013 between 10:10 am and 11:00 am, revealed that following corridor doors failed to latch.

a. 10:10 am, corridor door to the kids dining room (needed excessive force to fully close and latch).
b. 10:45 am, room 150 (needed excessive force to fully close and latch).
c. 11:00 am, room 140 (failed to latch).

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above corridor doors failed to positively latch into their frames.

Based on observation and interview, it was determined the facility failed to maintain the corridor doors to positively latching into their frames in one of four smoke zones.

Findings include:

1. Observation on July 29, 2013 at 10:30 am, revealed the door of room 5 did not have a latching mechanism and could not positively latch into the door frame.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the corridor door requires adjustment.


2. Observation on July 29 2013, at 10:45 am, revealed the corridor door of the isolation suite failed to stay latched when pressure was applied.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the corridor door requires adjustment.

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors resist the passage of smoke, are free of damage and impediments to closing, and positively latch when tested in four of four smoke zones within this component.

Findings include:

1. Observations made on July 29, 2013, between 10:01 am, and 11:16 am, revealed corridor doors that failed to positively latch when tested in the following locations:
a. 10:01 am, N 4 unit patient room 103, latching hardware missing.
b. 10:03 am, N 4 unit patient room 10, latching hardware missing.
c. 10:34 am, N 2 unit patient room 136, latching hardware missing.
d. 10:40 am, N 2 unit Quiet room, door failed to positively latch.
e. 10:43 am, N 2 unit patient room 154, latching hardware missing.
f. 11:05 am, N 1 unit patient room 232, latching hardware missing.
g. 11:13 am, N 1 unit Quiet room, latch hardware stuck in recessed position.
h. 11:16 am, N 1 unit patient room 202, latching hardware missing.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the improper and unauthorized use of power strips, extension cords and outlet multipliers in the above named locations.

2. Observation made on July 29, 2013, at 11:15 am, revealed that on the N 1 unit, the door to patient room 200 was starting to delaminate at the bottom half of the door.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the door was damaged.


3. Observation made on July 29, 2013, at 11:17 am, revealed that in the N 1 unit, the door to the Social Services office door was propped open by a chair.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed and the subsequent correction of the deficiency during the time of the survey.


4. Observation made on July 29, 2013, at 11:19 am, revealed that on the N 1 unit, the door to patient room 206 had a gap greater than one half inch between the door and the top of the frame, which would not resist the passage of smoke.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the door was not smoke tight.


5. Observation made on July 29, 2013, at 10:26 am, revealed that on the N 3 unit Quiet room, the corridor door had four circular holes that penetrate the door near the handle where aprevious hardware had been removed.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the holes in the door.

Based on observation and interview, it was determined that the facility failed to ensure that smoke barrier walls maintain a fire resistive rating free of unsealed penetrations in two of two smoke zones within this component.

Findings Include:

Observation made on July 2913, at 9:40 am, revealed at the smoke barrier wall at the N3 unit by room 153, there was a red fire alarm wire that was sealed with a grey latex material. The facility could not produce documentation verifying the fire rating at the time of the survey.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed there was a smoke barrier penetration.

Based on observation and interview, it was determined that the facility failed to maintain hazardous areas within a smoke tight separation, in sprinklered locations, in one of three smoke zones within this component.

Findings include:

Observation made on July 29, 2013 at 9:50 am, revealed that in the basement the boiler room door had its latch receiver taped over, preventing the door from latching.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above hazardous area door failed to latch.

Based on observation and interview, it was determined the facility failed to maintain clear acces to the exit egress in two of four smoke zones.

Findings include:

1. Observation on July 29, 2013 between 10:00 am and 10:25 am, revealed table and chairs were placed in the exit access at the following locations:

a. 10:00 am, Pod B, Day Room, a table and two wheeled office chairs were unattended in the corridor between the patio and the lobby access doors.
b. 10:25 am, Pod C, Day Room, a table and wheeled office chair were in the corridor between the linen storage closet and the lobby access doors, but were attended by a staff member.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the table and chairs were in the exit access.

Based on documentation review and interview, it was determined that the facility failed to ensure that fire drills are being conducted during varied times within this component.

Findings Include:

Document review made on July 29, 2013, between 1:00 pm, and 2:30 pm, revealed that the fire drills for the main building were not being conducted during varying times for the second and third shifts, as follows:

Second shift:
February 27, 2013, 4:02 pm.
May 29, 2013, 3:55 pm,
August 14, 2012, 4:00 pm.
November 30, 2012, 3:55 pm.

Third shift:
March 28, 2013, 5:56 am,
June 27, 2013, 6:01 am,
September 27, 2012, 5:59 am,
December 27, 2012, 6:00 am.

The fire drills were being conducted towards the end of the month and close to the end of the hour.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the the fire drills were not being conducted during varied times.

Based on observation and interview, it was determined the facility failed to maintain fire alarm notification devices in an operable condition in one of four smoke zones.

Findings include:

Observation on July 29, 2013 at 10:40 am, revealed that the heat detector in the Arts & Crafts Area was hanging below the ceiling level, leaving a gap between the detector and the ceiling.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the heat detector was not in a smoke tight assembly.

Based on observation and interview, it was determined that the facility failed to ensure that buildings, which are classified as fully sprinklered, had maintained sprinkler protection in all required areas in one of three smoke zones within this component..

Findings include:

Observation made on July 29, 2013 at 9:55 am, revealed that the basement level electrical room lacked sprinkler coverage. There were two branch lines in the room capped off.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the basement electrical room lacked sprinkler coverage.

Based on observation and interview, it was determined that the facility failed to ensure that complete automatic sprinkler protection is provided in buildings classified as fully sprinklered and there are no obstructions to activation of sprinkler heads in five smoke zones within this component.

Findings Include:

1. Observation made on July 29, 2013, at 10:12 am, revealed that in the N4 unit quiet room, the small sink room lacks sprinkler protection.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the sink room lacked sprinkler protection.


2. Observation made on July 29, 2013, at 11:30 am, revealed the Attic space lacks sprinkler protection. The attic area runs the full length of the building and houses mechanical air handling ductworks and IT equipment racks.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the attic space lacks sprinkler protection.


3. Observations made on July 29, 2013, between 10:20 am, and 10;28 am, revealed sprinkler heads with buildup of dirt and debris, which could delay the activation of the sprinkler in the following locations:

10:20 am, N3 unit corridor by nurse station and staff lounge 124.
10:28 am, N3 unit laundry room.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the build up of dirt and debris in the above named locations.


4. Observation made on July 29, 2013, at 8:21 am, revealed that in the front entrance vestibule the sprinkler head was missing an escutcheon plate and was not smoke tight.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the missing escutcheon plate for the sprinkler head.


5. Observation made on July 29, 2013, at 10:00 am, revealed that in the N4 unit day room closet, the sprinkler head had become detached from the monolithic ceiling assembly and was not smoke tight.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the sprinkler head was detached from the monolithic ceiling.


6. Observations made on July 29, 2013, between 9:36 am, and 10:53 am, revealed missing and broken ceiling tiles and monolithic ceiling assemblies that were not smoke tight, which could delay activation of sprinkler heads in the following locations:

a. 9:36 am, Housekeeping closet 136, hole in monolithic ceiling.
b. 10:11 am, N4 unit Quiet room, gap around the sprinkler head.
c. 10:36 am, N2 unit day room by the television set, pipe penetrating the ceiling tile and the hole around the pipe is not smoke tight. This condition was seen in other day rooms.
d. 10:53 am, N2 unit clean linen room 220, ceiling tiles had being removed.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the non- smoke tight ceiling assemblies in the above named locations.


7. Observation made on July 29, 2013, at 11:14 am, revealed that inside the N1 unit mechanical room, the drop down ladder attic access door was in the open position, exposing the mechanical space to the attic. The mechanical room is also being used to store large linen carts that were preventing the access door from closing. The linen carts where filled to the point that bags of linen were within eighteen inches of the sprinkler heads.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the open access door and obstructions to the sprinkler heads.

Based on observation and interview, it was determined that the facility failed to maintain sprinkler components in reliable operating condition and kept free of obstructions in three of three smoke zones within this component.

Findings include:

1. Observation made on July 29, 2013 at 9:47 am, revealed in the basement level boiler room, the following items were noted:

a. One sprinkler head was covered with plastic
b. One sprinkler head had spray fire proofing applied. This sprinkler head must be replaced.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above location had obstructed sprinkler heads.

2. Observation made on July 29, 2013 between 10:52 am and 11:35 am, revealed that the following locations had solid shower curtains that would obstruct the water development pattern of the sprinkler heads:

a. 10:52 am, room 147.
b. 10:55 am, room 145.
c. 11:25 am, the entire N5 wing with the exception of rooms 124, 125 and 126.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above locations had solid curtains obstructing the sprinkler heads.

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers readily accessible at all times in one of three smoke zones within this component.

Findings include:

Observation made on July 29, 2013 at 9:45 am, revealed that in the basement mechanical room near the rear exit, the fire extinguisher was blocked from access.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above fire extinguisher was blocked from access.

28 Pa. Code § 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. § 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal,State and local laws and regulations.

Findings include:

Observation on July 29, 2013 at 9:40 am, revealed the facility is undergoing renovations of the patient pods in order to install ligature resistant hardware and fixtures. The facility has not submitted a narration of the renovations or plans for review by the Department of Health.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the facility had not submitted documentation of renovations for review.

Based on observation and interview, it was determined that the facility failed to prevent the unauthorized use of electrical devices and did not remove temporary wiring after use in two of three smoke zones within this component.

Findings include:

1. Observation made on July 29, 2013 between 10:25 am and 11:40 am, revealed the unauthorized or improper use of electrical devices at the following locations:

a. 10:25 am, room 166 group therapy office (extension cord in use).
b. 10:30 am, room 166 group therapy office (microwave powered by a powerstrip powered by a extension cord).
c. 11:05 am, N5 Chart room (coffee maker powered by a extension cord).

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed at the above locations there was unauthorized or improper use of electrical devices found.

2. Observation made on July 29, 2013 at 11:05 am, revealed inside the N5 housekeeping closet above the drop ceiling, there was temporary lighting still in place.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed the above location had temporary lighting in place.

Based on observation and interview, it was determined the facility failed to monitor for the unauthorized use of electrical devices in one of four smoke zones.

Findings include:

1. Observation on July 29, 2013 between 9:10 am and 9:30 am, revealed extension cords were being used at the following locations:

a. 9:10 am, Utilization Review Office.
b. 9:30 am, Doctor's Office.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013 at 2:30 pm, confirmed there were extension cords being used.


2. Observation on July 29, 2013 between 9:12 and 9:25 am, revealed surge protectors were being used to power appliances at the following locations:

a. 9:12 am, Utilization Review Office.
b. 9:25 am, Doctor's Office.

Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the surge protectors were being used in an unauthorized manner.

Based on observation and interview, it was determined that the facility failed to prevent the unauthorized use of electrical devices and protect electrical wiring in in four of four smoke zones within this component.

Findings include:

1. Observations made on July 29, 2013, between 8:56 am, and 11:10 am, revealed the unauthorized and improper use of extension cords, powerstrips, and outlet multipliers in the following locations:
a. 8: 56 am, ground floor conference room, refrigerator, coffee maker and water cooler plugged into a powerstrip that had damaged outlets.
b. 9:28 am, Chief Executive Officer office, extension cord plugged into a powerstrip that was powering a refrigerator.
c. 9:33 am, Utilization office 138, refrigerator plugged into a powerstrip.
d. 10:08 am, N4 unit Doctors office, brown extension cord in use plugged into a powerstrip and a microwave oven plugged into a powerstrip.
e. 10:37 am, N2 unit Medications room, small refrigerator plugged into an colored extension cord.
f. 11:10 am, N1 Social Worker office, middle desk area, six plug outlet multiplier in use.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the unauthorized use of electrical devices.


2. Observation made on July 29, 2013, at 10:55 am, revealed inside the N 2 unit Housekeeping closet, there was an electrical outlet that was missing a protective face plate cover.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the missing electrical outlet face plate.

3. Observation made on July 29, 2013, at 11:47 am, revealed that inside the exterior accessed generator room, that houses the older generator set, there was an open junction box at the rear of the building next to the wall mounted electrical meter.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the open junction box.

4. Observation made on July 29, 2013, at 11:30 am, revealed that in the attic space above the N1 unit access steps, there was yellow contractor 's temporary wiring lying on top of the ceiling tile assembly.
Interview with the CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management at the exit interview on July 29, 2013, at 2:30 pm, confirmed the temporary wiring in the attic space.