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Based on observation and interview it was determined the facility failed to properly maintain one fire extinguisher placement in one of five smoke compartments in this component.

Findings include:

A. Observation on April 26, 2011, 9:47 AM, revealed a fire extinguisher cabinet marker light, located in the ED waiting room, was not working.

Interview with maintenance representative #1 on April 26, 2011, 9:48 AM, confirmed the fire extinguisher cabinet marker light was not lit.

Based on observation and interview it was determined the facility failed to properly configure two medical gas storage areas in two of five smoke compartments in this component.

Findings include:

A. Observation on April 26, 2011, between 9:37 AM and 9:43 AM, revealed the following:

1. 9:37 AM - First floor radiology developer room was being utilized as a medical gas storage area. This storage room had the following deficiencies:

Light switch located less than 5 feet above the floor.
Electrical receptacles located less than 5 feet above the floor.
No door separating this area from the remainder of radiology department.

2. 9:43 AM - First floor ED storage room was being utilized as a medical gas storage area. This storage room had the following deficiencies:

Light switch located less than 5 feet above the floor.
Electrical receptacles located less than 5 feet above the floor.
No door separating this area from the remainder of radiology department.
Medical gas cylinders located closer than 20 feet from combustibles.

Interview with maintenance representative #1 on April 26, 2011, at 9:45 AM, confirmed these locations were not properly configured for medical gas storage.

Based on observation and interview it was determined the facility failed to properly maintain installed medical gas distribution piping in one of five smoke compartments on one of two stories in this component.

Findings include:

A. Observation on April 26, 2011, at 10:29 AM, revealed that Ground floor, medical gas piping, located in the corridor adjacent to the Lab Staff office, had steel clamps supporting the copper piping.

Interview with maintenance representative #1 on April 26, 2011, at 10:30 AM, confirmed the unauthorized use of dissimilar metals to support copper medical gas piping.

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 items did not conform to applicable Federal, State and local laws and regulations.

Based on observation and interview, it was determined the facility failed to provide hospital inpatient care and diagnostic services within buildings inspected and approved by the Department of Health.

Findings include:

1. Interview with Department of Health, Division of Acute and Ambulatory Care surveyor, on May 02, 2011, at 10:58 AM revealed the facility was providing MRI diagnostic imaging services to inpatients within a building that had not been inspected by the Division of Safety Inspection for compliance with NFPA 101, 2000 edition, Life Safety Code requirements. The outpatient MRI building, identified as the MRI Center located at the campus of Divine Providence Hospital, Grampian Boulevard, Williamsport, PA 17701.

Interview with hospital administrator on May 02, 2011, at 02:00 PM confirmed that hospital inpatients were receiving MRI services within a building not inspected and approved by the Department of Health.

28 Pa. Code ? 101.42a Code Compliance.

Based on observation and interview it was determined the facility failed to properly maintain the installed electrical power distribution system in one of five smoke compartments in this component.

Findings include:

A. Observation on April 26, 2011, at 10:32 AM, revealed an unauthorized surge suppressor power strip was being utilized to provide power to a microwave and a coffee maker in the basement multipurpose room.

Interview with maintenance representative #1 on April 26, 2011, at 10:34 AM, confirmed the unauthorized use of a surge suppressor power strip.

Based on observation and interview it was determined the facility failed to properly maintain one fire extinguisher placement in one of five smoke compartments in this component.

Findings include:

A. Observation on April 26, 2011, 9:47 AM, revealed a fire extinguisher cabinet marker light, located in the ED waiting room, was not working.

Interview with maintenance representative #1 on April 26, 2011, 9:48 AM, confirmed the fire extinguisher cabinet marker light was not lit.

Based on observation and interview it was determined the facility failed to properly configure two medical gas storage areas in two of five smoke compartments in this component.

Findings include:

A. Observation on April 26, 2011, between 9:37 AM and 9:43 AM, revealed the following:

1. 9:37 AM - First floor radiology developer room was being utilized as a medical gas storage area. This storage room had the following deficiencies:

Light switch located less than 5 feet above the floor.
Electrical receptacles located less than 5 feet above the floor.
No door separating this area from the remainder of radiology department.

2. 9:43 AM - First floor ED storage room was being utilized as a medical gas storage area. This storage room had the following deficiencies:

Light switch located less than 5 feet above the floor.
Electrical receptacles located less than 5 feet above the floor.
No door separating this area from the remainder of radiology department.
Medical gas cylinders located closer than 20 feet from combustibles.

Interview with maintenance representative #1 on April 26, 2011, at 9:45 AM, confirmed these locations were not properly configured for medical gas storage.

Based on observation and interview it was determined the facility failed to properly maintain installed medical gas distribution piping in one of five smoke compartments on one of two stories in this component.

Findings include:

A. Observation on April 26, 2011, at 10:29 AM, revealed that Ground floor, medical gas piping, located in the corridor adjacent to the Lab Staff office, had steel clamps supporting the copper piping.

Interview with maintenance representative #1 on April 26, 2011, at 10:30 AM, confirmed the unauthorized use of dissimilar metals to support copper medical gas piping.

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 items did not conform to applicable Federal, State and local laws and regulations.

Based on observation and interview, it was determined the facility failed to provide hospital inpatient care and diagnostic services within buildings inspected and approved by the Department of Health.

Findings include:

1. Interview with Department of Health, Division of Acute and Ambulatory Care surveyor, on May 02, 2011, at 10:58 AM revealed the facility was providing MRI diagnostic imaging services to inpatients within a building that had not been inspected by the Division of Safety Inspection for compliance with NFPA 101, 2000 edition, Life Safety Code requirements. The outpatient MRI building, identified as the MRI Center located at the campus of Divine Providence Hospital, Grampian Boulevard, Williamsport, PA 17701.

Interview with hospital administrator on May 02, 2011, at 02:00 PM confirmed that hospital inpatients were receiving MRI services within a building not inspected and approved by the Department of Health.

28 Pa. Code ? 101.42a Code Compliance.

Based on observation and interview it was determined the facility failed to properly maintain the installed electrical power distribution system in one of five smoke compartments in this component.

Findings include:

A. Observation on April 26, 2011, at 10:32 AM, revealed an unauthorized surge suppressor power strip was being utilized to provide power to a microwave and a coffee maker in the basement multipurpose room.

Interview with maintenance representative #1 on April 26, 2011, at 10:34 AM, confirmed the unauthorized use of a surge suppressor power strip.