HospitalInspections.org

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to provide a plan for the role of the facility under a waiver declared by the Secretary of the Department of Health.

Findings include:

1. Interview and documentation review on January 30, 2024, at 9:00 a.m., revealed procedures to address the role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials, was not included in the EP plan.

Interview with the Safety Manager on January 30, 2024 at 9:00 a.m. confirmed the EP plan lacked a written plan of the facility's role during a waiver declared by the Secretary of the Department of Health.

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to fully develop and maintain an EP program for training and testing staff.

Findings include:

1. Interview and documentation review on January 30, 2024, at 9:10 a.m., revealed the facility's EP training and testing policy failed to indicate what type and recurrence of training and testing is required to demonstrate staff knowledge of emergency procedures.

Interview with the Safety Manager on January 30, 2024, at 9:10 a.m., confirmed the facility performed required EP training and testing, however the EP training policy does not indicate what the requirement is.

28 Pa. Code § 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. 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 facility failed to obtain approval from the Division of Safety Inspection, Plan Review Department prior to conducting rehabilitation work in one instance, affecting one of three floors.

Findings include:

1. Observation January 31, 2024, at 12:55 p.m. revealed that work was being performed to the ceiling of the entire first floor. Plan Review was not notified and there were no state approved plans on-site.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed that Plan Review had not been contacted prior to beginning the ceiling rehabilitation project.

Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in three instances, affecting five of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, revealed the following vertical opening enclosure deficiencies:

a) 11:40 a.m., there was an unsealed conduit penetration above the door inside pipe chase closet 257;
b) 12:32 p.m., there were two large, unsealed penetrations in the concrete deck above, in basement storage room 0053;
c) 12:45 p.m., there were multiple unsealed pipe penetrations in the concrete deck above, in basement closet 0025 A, off the kitchen storage room.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed vertical opening enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 12:38 p.m., revealed the facility failed to maintain the required one-hour fire rating for hazardous area enclosures in storage room 0021A. There were multiple unsealed penetrations in the walls.


Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed hazardous area enclosure deficiency.

Based on observation and interview, it was determined the facility failed to install required fire alarm system components in one instance, affecting the entire facility.

Findings include:

1. Observation on January 30, 2024, at 10:20 a.m., revealed there was no automatic smoke or heat detector at the main fire alarm control panel on the first floor.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed there was not a smoke detector at the main fire alarm panel.

Based on observation and interview, it was determined the facility failed to maintain the automatic fire alarm system in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 10:45 a.m., revealed the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic fire alarm system. There was a large section of the ceiling missing in the activities air handler room in the basement.


Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed automatic fire alarm system deficiency.

Based on observation and interview, it was determined the facility failed to maintain smoke detection in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 11:59 a.m., revealed a smoke detector hanging by its wires near room 0051 in the basement.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the smoke detection deficiency.

Based on observation and interview, it was determined the facility failed to maintain smoke detection systems in three instances, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, revealed the following smoke detection deficiencies:

a) 10:20 a.m., the smoke detector outside the linen room in the basement was hanging by its wires;
b) 10:21 a.m., there were three ceiling tiles missing inside the linen room, which may affect smoke detection;
c) 10:30 a.m., the smoke detector near room 0045, in the basement, was covered with plastic and tape.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the smoke detection deficiences.

Based on review of documentation, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in eight instances, affecting the entire building.

Findings include:

1. Document review on January 30, 2024, revealed the facility lacked documentation for the following:
a) 8:30 a.m., a five-year internal pipe inspection;
b) 8:32 a.m., documentation that water pressure gages throughout the building (dated 2015) have been changed or recalibrated within the last five years.
Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the facility lacked the sprinkler system documentation at the time of the survey.

2. Observation on January 31, 2024, revealed the following automatic sprinkler system deficiencies. The facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation of the automatic sprinkler system in the following locations:

a) 11:12 a.m., there was a large, unsealed gap where the wall meets the ceiling in the dentist's office;
b) 11:17 a.m., there was an unsealed drainpipe in the ceiling of the closet in nurse-station 135;
c) 11:28 a.m., there was a large, unsealed gap where the wall meets the ceiling in storage room 241;
d) 11:30 a.m., there was a large, unsealed gap where the wall meets the ceiling in the social services office 243;
e) 11:55 a.m., there was a large hole in the ceiling of basement office 0055;
f) 11:58 a.m., there were multiple missing ceiling tiles in storage/pump room 0054.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in one instance, affecting one of three floors.

Findings include:

1. Observation on January 30, 2024, at 11:10 a.m., revealed there was no Class K fire extinguisher in the canteen kitchen on the ground floor.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the lack of a Class K extinguisher in the kitchen within 30 feet of the cooking equipment.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 11:35 a.m., revealed holes in the corridor wall outside of Med Room 253, on the second floor.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the unsealed penetrations in the corridor wall.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 10:15 a.m., revealed one of the 0001 smoke barrier doors was missing in the basement.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the missing smoke barrier door.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting one of eight smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code...19.5.1.1, NFPA 101.

Findings include:

1. Observation on January 31, 2024, at 10:21 a.m., revealed an open electrical junction box above HVAC unit AHU2 in the basement HVAC Room.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed electrical wiring deficiency.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 11:24 a.m., revealed an outlet within six feet of a sink was not GFCI protected in the South 2 Med Room, on the second floor.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the outlet was not GFCI protected.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of nine smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 1:13 p.m., revealed an outlet within six feet of a sink was not GFCI protected in Podiatry Exam Room 250A, on the second floor.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the outlet was not GFCI protected.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 10:38 a.m., revealed an outlet was not GFCI protected near the sink in the basement activities room.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the outlet within six feet of the sink was not GFCI protected.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 30, 2024, at 10:07 a.m., revealed an outlet within six feet of a sink was not GFCI protected in the canteen storage room on the first floor.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the outlet was not GFCI protected.

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator, affecting the entire facility. 6.4.1.1.16.2, NFPA 99

Findings include:

1. Observation on January 31, 2024, at 11:03 a.m., revealed the emergency generator remote manual stop station, located outside of the generator enclosure, was not connected.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the remote manual stop switch outside of the generator enclosure was not connected.

Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator, affecting the entire facility. 6.4.1.1.16.2, NFPA 99

Findings include:

1. Observation on January 31, 2024, at 1:47 p.m., revealed the emergency generator remote manual stop station, located outside of the generator enclosure, was not connected.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the remote manual stop switch outside of the generator enclosure was not connected.

Based on observation and interview, it was determined the facility failed to maintain the remote alarm annunciator for the emergency generator, affecting the entire facility.

Findings include:

1. Observation on January 31, 2024, at 1:50 p.m., revealed the only remote generator annunciator was located in a first floor nurse station that is not readily observed due to the unit being closed for renovations.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the remote annunciator was not readily observed by facility personnel.

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months.

Findings include:

1. Review of documentation on January 30, 2024, revealed the facility lacked documentation verifying that the following items were performed in the last twelve months:
a) 9:38 a.m., the annual fuel quality test;
b) 9:42 a.m., the three year four hour test.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the required annual generator testing documentation was not available at the time of the survey.

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance and testing for 12 of the last 12 months.

Findings include:

1. Review of documentation on January 30, 2024, at 9:30 a.m., revealed the facility lacked documentation verifying the annual fuel quality test was performed.
Interview with the Facility Administrator and Facility Staff, on January 31, 2024, at 2:00 p.m., confirmed the required annual generator testing documentation was not available at the time of the survey.

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months.

Findings include:

1. Review of documentation on January 30, 2024, revealed the facility lacked documentation verifying that the following items were performed in the last twelve months:
a) 9:40 a.m., the annual fuel quality test;
b) 9:45 a.m., the three year four hour test.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the required annual generator testing documentation was not available at the time of the survey.

Based on documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months.

Findings include:

1. Review of documentation on January 30, 2024, at 9:30 a.m., revealed the facility lacked documentation verifying the annual fuel quality test was performed.
Interview with the Facility Administrator and Facility Staff, on January 31, 2024, at 2:00 p.m., confirmed the required annual generator testing documentation was not available at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of eight smoke compartments.

Findings include:

1. Observation on January 31, 2024, at 10:19 a.m., revealed a microwave and a refrigerator plugged into a power strip in the basement HVAC room.

Interview with the Facility Administrator and Facility Staff on January 31, 2024, at 2:00 p.m., confirmed the listed electrical wiring systems and equipment deficiency.