HospitalInspections.org

Based upon observation and interview, the facility failed to maintain the requirements for a two hour fire door in one location on one of four floors.

Findings include:

1. Observation on December 4, 2012, at 09:20 a.m. revealed the two hour door separation in the cafeteria area had holes in the door.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the two hour door had holes in it.

Based upon observation and interview, the facility failed to maintain / seal vertical penetrations in one area on one of four floors.

Findings include:

1. Observation on December 3, 2012, at 13:35 p.m. revealed a vertical penetration in the old telecom closet on the 2nd floor near the Bio-Med shop.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the vertical penetrations existed.

Based on observation and interview, it was determined the facility failed to provide the proper fire resistance rating of smoke barrier openings in one location on one of five floors.

Findings include:

Observation on December 4, 2012, at 10:21 a.m. revealed the Ground floor ER Registration window rated drop down curtain was blocked by a registration book.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed the curtain was blocked.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations in two areas on two of four floors.

Findings include:

1. Observation on December 3, 2012, at 14:05 p.m. revealed the office on the 1st floor Administration wing across from the Grant Coordinators office was being used as a storage room. The room and the door to the room do not meet the requirements for a storage location.
2. Observation on December 4, 2012, at 09:05 a.m. revealed several doors in the kitchen area including storage rooms that were being held open with unauthorized devices.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the hazardous areas above did not meet the requirements.

Based upon observation and interview, the facility failed to maintain exit access and unobstructed corridors in one area on one of four floors.

Findings include:

1. Observation on December 3, 2012, at 14:15 p.m. revealed that computers on wheels with stationary chairs at the same locations were being left unattended in the corridors in the AC1 area.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the corridors were being obstructed.

Based on observation and interview, it was determined the facility failed to ensure that exit access corridors were maintained clear and unobstructed in one area on one floor.

Findings include:

Observation on December 3, 2012, at 2:43 p.m. revealed the 3rd floor Speciality Care had a scale and a Blood Pressure machine stored in the corridor across from the Med Room and Clean Utility Room..

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the corridor was obstructed.

Based on documentation review and interview, the facility failed to maintain battery-powered emergency lighting in accordance with the regulations.

Findings include:

Review of documentation on December 4, 2012, between 8:00 a.m. and 9:00 a.m. revealed the facility lacked documentation reflecting the battery-powered emergency lighting units in the ORs were being inspected monthly and annually.
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Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there was no documentation for battery-powered emergency lighting.

Based on review of documentation and interview, it was determined that the sprinkler system was not being maintained.

Findings include:

Review of documentation on December 4, 2012, between 8:00 a.m. and 9:00 a.m. revealed the quarterly sprinkler inspection dated 4/9/12 indicated the ground floor maintenance corridor tamper switch failed, and there was no documentation indicating that it had been repaired.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there was no documentation for the tamper switch.

Based on observation and interview, it was determined that the facility's smoking area was not in accordance with the regulations.

Findings include:

Observation on December 3, 2012, at 9:41 a.m. revealed the designated outside smoking area had cigarette butts in the trash can with combustibles, and there was no required metal butt can with a self closing lid. into which ashtrays could be emptied.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there was cigarette butts placed in the trash can and there was no butt can.

Based upon observation and interview, the facility failed to maintain storage of medical gas and CO2 cylinders in compliance with requirements in two areas on two of four floors.

Findings include:

1. Observation on December 3, 2012, at 13:45 p.m. revealed the oxygen storage in the 2nd floor Pre-op holding area is not labeled full and empty and segregated.
2. Observation on December 4, 2012. at 09:00 a.m. revealed two unsecured CO2 cylinders in the kitchen storage room area.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the cylinders were unsecured and not separated.

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:

1. Observation on December 3, 2012, at 11:00 a.m. revealed the facility lacked a portable, accurate set of floor plans per DOH DSI Message Board dated 7/1/08 "Life Safety Code Floor Plans." As such, smoke walls could not be inspected during the survey and will have to be inspected on the revisit.

2. Observation on December 4, 2012, at 8:50 a.m. revealed seven (7) cans of combustible cooking fuel and four (4) cans of butane being stored in the kitchen storage / break room. Per chapter 12.7.2 of the Life Safety Code these items are not permitted.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there were no accurate/portable floor plans and the cooking fuel and butane were in the kitchen storage room.

Based on documentation review and interview the facility failed to maintain the emergency generator, which supplies power to the entire building.

Findings include:

Review of documentation on December 4, 2012, between 8:00 a.m. and 9:00 a.m. revealed there was no documentation indicating that a load bank was performed on the generator during the past 12 months.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there was no documentation for the load bank test.

Based upon observation and interview, the facility failed to maintain electrical wiring and/or equipment in compliance with NFPA 70, the National Electrical Code in two areas on two of four floors.

Findings include:

1. Observation on December 3, 2012, at 13:20 p.m. revealed appliances plugged into surge protectors on the 2nd floor in the Blair Medical break room and the Bio-Med area.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the appliances were plugged into surge protectors.

Based upon observation and interview, the facility failed to install alcohol based hand sanitizers (ABHS) according to regulations in one area on one of four floors.

Findings include:

1. Observation on December 3, 2012, at 11:00 a.m. revealed that the Alcohol based hand sanitizer in the 3rd floor Maternity soiled room was installed directly over an electrical outlet/switch.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the ABHS was installed over the electric switch.

Based upon observation and interview, the facility failed to maintain the requirements for a two hour fire door in one location on one of four floors.

Findings include:

1. Observation on December 4, 2012, at 09:20 a.m. revealed the two hour door separation in the cafeteria area had holes in the door.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the two hour door had holes in it.

Based upon observation and interview, the facility failed to maintain / seal vertical penetrations in one area on one of four floors.

Findings include:

1. Observation on December 3, 2012, at 13:35 p.m. revealed a vertical penetration in the old telecom closet on the 2nd floor near the Bio-Med shop.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the vertical penetrations existed.

Based on observation and interview, it was determined the facility failed to provide the proper fire resistance rating of smoke barrier openings in one location on one of five floors.

Findings include:

Observation on December 4, 2012, at 10:21 a.m. revealed the Ground floor ER Registration window rated drop down curtain was blocked by a registration book.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed the curtain was blocked.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations in two areas on two of four floors.

Findings include:

1. Observation on December 3, 2012, at 14:05 p.m. revealed the office on the 1st floor Administration wing across from the Grant Coordinators office was being used as a storage room. The room and the door to the room do not meet the requirements for a storage location.
2. Observation on December 4, 2012, at 09:05 a.m. revealed several doors in the kitchen area including storage rooms that were being held open with unauthorized devices.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the hazardous areas above did not meet the requirements.

Based upon observation and interview, the facility failed to maintain exit access and unobstructed corridors in one area on one of four floors.

Findings include:

1. Observation on December 3, 2012, at 14:15 p.m. revealed that computers on wheels with stationary chairs at the same locations were being left unattended in the corridors in the AC1 area.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the corridors were being obstructed.

Based on observation and interview, it was determined the facility failed to ensure that exit access corridors were maintained clear and unobstructed in one area on one floor.

Findings include:

Observation on December 3, 2012, at 2:43 p.m. revealed the 3rd floor Speciality Care had a scale and a Blood Pressure machine stored in the corridor across from the Med Room and Clean Utility Room..

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the corridor was obstructed.

Based on documentation review and interview, the facility failed to maintain battery-powered emergency lighting in accordance with the regulations.

Findings include:

Review of documentation on December 4, 2012, between 8:00 a.m. and 9:00 a.m. revealed the facility lacked documentation reflecting the battery-powered emergency lighting units in the ORs were being inspected monthly and annually.
.
Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there was no documentation for battery-powered emergency lighting.

Based on review of documentation and interview, it was determined that the sprinkler system was not being maintained.

Findings include:

Review of documentation on December 4, 2012, between 8:00 a.m. and 9:00 a.m. revealed the quarterly sprinkler inspection dated 4/9/12 indicated the ground floor maintenance corridor tamper switch failed, and there was no documentation indicating that it had been repaired.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there was no documentation for the tamper switch.

Based on observation and interview, it was determined that the facility's smoking area was not in accordance with the regulations.

Findings include:

Observation on December 3, 2012, at 9:41 a.m. revealed the designated outside smoking area had cigarette butts in the trash can with combustibles, and there was no required metal butt can with a self closing lid. into which ashtrays could be emptied.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there was cigarette butts placed in the trash can and there was no butt can.

Based upon observation and interview, the facility failed to maintain storage of medical gas and CO2 cylinders in compliance with requirements in two areas on two of four floors.

Findings include:

1. Observation on December 3, 2012, at 13:45 p.m. revealed the oxygen storage in the 2nd floor Pre-op holding area is not labeled full and empty and segregated.
2. Observation on December 4, 2012. at 09:00 a.m. revealed two unsecured CO2 cylinders in the kitchen storage room area.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the cylinders were unsecured and not separated.

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:

1. Observation on December 3, 2012, at 11:00 a.m. revealed the facility lacked a portable, accurate set of floor plans per DOH DSI Message Board dated 7/1/08 "Life Safety Code Floor Plans." As such, smoke walls could not be inspected during the survey and will have to be inspected on the revisit.

2. Observation on December 4, 2012, at 8:50 a.m. revealed seven (7) cans of combustible cooking fuel and four (4) cans of butane being stored in the kitchen storage / break room. Per chapter 12.7.2 of the Life Safety Code these items are not permitted.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there were no accurate/portable floor plans and the cooking fuel and butane were in the kitchen storage room.

Based on documentation review and interview the facility failed to maintain the emergency generator, which supplies power to the entire building.

Findings include:

Review of documentation on December 4, 2012, between 8:00 a.m. and 9:00 a.m. revealed there was no documentation indicating that a load bank was performed on the generator during the past 12 months.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed there was no documentation for the load bank test.

Based upon observation and interview, the facility failed to maintain electrical wiring and/or equipment in compliance with NFPA 70, the National Electrical Code in two areas on two of four floors.

Findings include:

1. Observation on December 3, 2012, at 13:20 p.m. revealed appliances plugged into surge protectors on the 2nd floor in the Blair Medical break room and the Bio-Med area.

Interview with the Maintenance Director on December 4, 2012, at 11:30 a.m. confirmed that the appliances were plugged into surge protectors.