HospitalInspections.org

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations on one of four floors.

Findings include:

Observation on February 2, 2016 at 8:40 am revealed the third floor common wall doors 3F3 at the TCU lacked positive latching with the self-closer.

Interview with the Director of Environmental Services on February 2, 2016 at 8:40 am confirmed the common wall doors lacked positive latching with the self-closer.

Based upon observation and interview, the facility failed to maintain a two-hour common wall with a non-conforming building in one of two fire barriers.

Findings include:

Observation on February 3, 2016, at 10:00 am revealed ground floor fire barrier door hardware installed on door to Liberty Street Medical Arts Building (left side door) is labeled "panic hardware", instead of the required "fire exit hardware".

Interview with Vice President of Ancillary Services (VPAS) on February 3, 2016, at 10:00 am confirmed the door hardware is not labeled as "fire exit hardware".

Based on observation and interview, the facility failed to maintain proper building construction type on one of seven building levels.

Findings include:

Observation on February 3, 2016, at 9:45 am revealed ground floor lab (near West side windows) had an unsealed electrical circuit conduit for lab equipment that penetrated the fire rated floor assembly.

Interview with VPAS on February 3, 2016, at 9:45 am confirmed the unsealed floor penetration.

Based upon observation and interview, it was determined the facility failed to maintain doors protecting corridor openings in two of over 100 corridor doors.

Findings include:

1. Observation on February 2, 2016, at 12:18 pm revealed first floor Triage E.R. door is not smoke resistant (this is a split-access dutch door, that lacked an astragal).

Interview with VPAS on February 2, 2016, at 12:18 pm confirmed the corridor is not smoke resistant.

2. Observation on February 3, 2016, at 10:15 am revealed ground floor clean linen room corridor door lacked consistent positive latching with a self-closure.

Interview with VPAS on February 3, 2016, at 10:15 am confirmed the corridor door lacked consistent positive latching.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one hour.

Findings include:

Observation on February 2, 2016 at 9:15 am revealed the stairwell door (GS 12) from the basement assembly room lacked positive latching with the self-closer.

Interview with the Director of Environmental Services on February 2, 2016 at 9:15 am confirmed the stairwell door lacked positive latching with the self-closer.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one hour.

Findings include:

Observation on February 3, 2016 between 8:55 am and 9:30 am revealed the facility had unsealed vertical penetrations at the following locations:
a. The basement BASF1 had an unsealed penetration over the stairwell doors.
b. The basement elevator shaft had an unsealed penetrations from the electric cage into the elevator shaft.

Interview with the Director of Environmental Services on February 3, 2016 at 9:30 am confirmed the unsealed vertical penetrations.

Based upon observation and interview, it was determined the facility failed to maintain doors protecting hazardous openings in one of over twenty hazardous area doors.

Findings include:

Observation on February 2, 2016, at 10:20 am revealed second floor respiratory storage room door lacked positive latching with the self-closure.

Interview with VPAS on February 2, 2016, at 10:20 am confirmed the hazardous area door lacked positive latching.

Based upon observation and interview, the facility failed to maintain exit egress components with a fire rating of at least one hour, and provide a continuous path of egress, in three of seven exit stair towers.

Findings include:

Observation on February 2, 2016, between 8:45 am and 12:00 pm revealed the following stair tower concerns:
A. Fourth floor stair tower door to 4SF2 to Penthouse lacked consistent positive latching (8:45 am).
B. Third floor stair tower L3-FD12 had two unsealed penetrations (9:35 am).
C. First floor stair tower at entrance had two "cross walk" signs stored under the steps (12:00 pm).

Interview with VPAS on February 2, 2016, at 12:00 pm confirmed the above exit stair tower concerns.

Based upon observation and interview, the facility failed to maintain exit egress components to provide a continuous path of egress in one of over five exit discharges.

Findings include:

Observation on February 3, 2016, at 10:05 am revealed ground floor south wing exit to a public way had a concrete landing that is not solid, or free of projections, that could trip individuals.

Interview with VPAS on February 3, 2016, at 10:05 am confirmed the concrete landing was not level.

Based upon observation and interview the width of exit corridors are not clear and unobstructed in accordance with regulations on one of four floors.

Findings include:

Observation on February 2, 2016 at 9:30 am revealed the third floor rehab corridor had carts and were charging work stations on wheels in both sides of the corridor.

Interview with the Director of Environmental Services on February 2, 2016 at 9:30 am confirmed the facility had carts and work stations throughout the corridor.

Based on observation and interview, facility failed to maintain horizontal exits on one of one, two-hour fire barrier with another conforming building.

Findings include:

Observation on February 3, 2016, at 8:30 am revealed the two-hour fire barrier between M.R.I. building and Main building had multiple unsealed penetrations on both sides of fire barrier wall, above the ceiling tile.

Interview with Vice President of Ancillary Services on February 3, 2016, at 8:30 am confirmed the fire barrier had multiple unsealed penetrations.

Based on observation and interview, facility failed to maintain horizontal exits on one of one, two-hour fire barrier with another conforming building.

Findings include:

Observation on February 3, 2016, at 8:30 am revealed the two-hour fire barrier between Main building and M.R.I. building had multiple unsealed penetrations on both sides of fire barrier wall, above the ceiling tile.

Interview with VPAS on February 3, 2016, at 8:30 am confirmed the fire barrier had multiple unsealed penetrations.

Based upon interview, it was determined the facility failed to provide fire sprinkler coverage in elevator hoistways in four of four shafts containing combustible hydraulic fluids.

Findings include:

Interview with VPAS on February 3, 2015, at 11:30 am, (and later telephone conversation of February 8, 2016, at 12:05 pm) revealed four of four elevator shafts (containing combustible hydraulic fluids) within this component lacked fire sprinkler coverage.

Interview with VPAS on February 3, 2015, at 11:30 am confirmed the elevator shafts lacked fire sprinkler coverage.

Based upon interview, it was determined the facility failed to provide fire sprinkler coverage in elevator hoistways in one of one shafts containing combustible hydraulic fluids.

Findings include:

Interview with Vice President of Ancillary Services (VPAS) on February 3, 2015, at 11:30 am, (and later telephone conversation of February 8, 2016, at 12:05 pm) revealed one of one elevator shaft (containing combustible hydraulic fluids) within this component lacked fire sprinkler coverage.

Interview with VPAS on February 3, 2015, at 11:30 am confirmed the elevator shaft lacked fire sprinkler coverage.

Based on observation, documentation review, and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in three areas of the entire building.

Findings include:

Observation on February 2, 2016 at 1:05 pm revealed the sprinkler gauges in the fire pump room were not recalibrated or replaced as required at five year interval since January 2010.

Interview with the Director of Environmental Services on February 2, 2016 at 1:05 pm confirmed the sprinkler gauges were not recalibrated or replaced within the last five years.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in four of seven building levels.

Findings include:

1. Observation on February 2, 2016, between 9:40 am and 1:10 pm revealed the following sprinkler concerns:
A. Third floor corridor above ceiling tile had a load of data wires on the fire sprinkler pipe between room 389 and smoke barrier 3NS3 (9:40 am).
B. Third floor equipment room 396A had data wires wrapped around the fire sprinkler head (9:50 am).
C. Second floor area above stair tower 2SF2 had a load of wires on the fire sprinkler pipe (10:15 am).
D. First floor Post Indicator Valve located outside receiving dock had sight glass that could not be read "open/closed" because the glass was painted over (1:10 pm).
E. First floor receiving stair tower had a sprinkler valve that lacked permanent identification as to which valve it is (1:10 pm).

Interview with VPAS on February 2, 2016, at 1:10 pm confirmed the above fire sprinkler concerns.

2. Observation on February 3, 2016, between 9:25 am and 11:15 am revealed the following sprinkler concerns:
A. Ground floor G24 storage had wire wrapped around the fire sprinkler head (9:25 am).
B. Ground floor linen chute discharge room had a sprinkler valve that lacked permanent identification as to which valve it is (10:20 am).
C. Ground floor G39C sprinkler valve lacked permanent identification as to which valve it is (11:15 am).

Interview with VPAS on February 3, 2016, at 11:15 am confirmed the above fire sprinkler concerns.

Based on observation and interview, the facility failed to ensure the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on two of seven building levels.

Findings include:

1. Observation on February 2, 2016, between 12:10 pm and 12:50 pm revealed the following fire extinguisher concerns:
A. 72 fire extinguishers on the first floor lacked an annual inspection for 2016.
B. First floor fire extinguisher in purchasing/receiving corridor is not protected from physical damage due to the Plexiglass removed from cabinet (12:50 pm).

Interview with VPAS on February 2, 2016, at 12:50 pm confirmed the above fire extinguisher concerns.

2. Observation on February 3, 2016, at 10:22 am revealed the ground floor fire extinguisher in the back of environmental services is not protected from physical damage due to the Plexiglass removed from cabinet.

Interview with VPAS on February 3, 2016, at 10:22 am confirmed the fire extinguisher cabinet lacked Plexiglass protection.

Based upon observation and interview, the facility failed to maintain the medical gas storage area in one of one main oxygen storage location.

Findings include:

Observation on February 2, 2016, at 1:00 pm revealed the facility failed to segregate oxygen cylinders between full and empty in the first floor main medical gas storage/manifold location.

Interview with VPAS on February 2, 2016, at 1:00 pm confirmed the oxygen cylinders were not segregated between full and empty.

Based upon observation and interview, the facility failed to maintain the piped-in medical gas system in one of one main medical gas manifold room.

Findings include:

Observation on February 2, 2016, at 12:55 pm revealed first floor main medical gas storage/manifold location had two unsecured nitrogen cylinders.

Interview with VPAS on February 2, 2016, at 12:55 pm confirmed the unsecured nitrogen cylinders.

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 in one of one Kitchen.

Findings include:

Observation on February 3, 2016, at 11:00 am revealed ground floor kitchen dish room had three unsecured carbon dioxide cylinders.

Interview with VPAS on February 3, 2016, at 11:00 am confirmed the unsecured cylinders.

Based upon observation and interview, it was determined the facility failed to maintain electrical wiring and/or equipment on four of seven building levels.

Findings include:

1. Observation on February 2, 2016, between 8:50 am and 12:35 pm revealed the following electrical concerns:
A. Fourth floor room 456 sleep lab had a C-pap machine plugged into a surge protector (8:50 am).
B. Fourth floor room 457 sleep lab had a C-pap machine plugged into a surge protector (8:53 am).
C. Fourth floor corridor between smoke barrier and 471 visitor lounge had an unsecured open junction box above the ceiling tile (9:00 am).
D. Second floor office 259 had a surge protector plugged into another surge protector (10:18 am).
E. First floor X-ray room 130 had a suspended surge protector hanging by the appliances plugged into it (12:35 pm).

Interview with VPAS on February 2, 2016, at 12:35 pm confirmed the above electrical concerns.

2. Observation on February 3, 2016, between 9:35 am and 9:50 am revealed the following electrical concerns:
A. Ground floor switchboard area had a refrigerator plugged into a surge protector (9:35 am).
B. Ground floor lab chem-freezer was plugged into an extension cord (9:50 am).

Interview with VPAS on February 3, 2016, at 9:50 am confirmed the above electrical concerns.

Based upon observation it was determined that facility representatives failed to ensure the two (2) hour common wall and/or doors as directed by regulations on one of four floors.

Findings include:

Observation on February 2, 2016 at 8:40 am revealed the third floor common wall doors 3F3 at the TCU lacked positive latching with the self-closer.

Interview with the Director of Environmental Services on February 2, 2016 at 8:40 am confirmed the common wall doors lacked positive latching with the self-closer.

Based upon observation and interview, the facility failed to maintain a two-hour common wall with a non-conforming building in one of two fire barriers.

Findings include:

Observation on February 3, 2016, at 10:00 am revealed ground floor fire barrier door hardware installed on door to Liberty Street Medical Arts Building (left side door) is labeled "panic hardware", instead of the required "fire exit hardware".

Interview with Vice President of Ancillary Services (VPAS) on February 3, 2016, at 10:00 am confirmed the door hardware is not labeled as "fire exit hardware".

Based on observation and interview, the facility failed to maintain proper building construction type on one of seven building levels.

Findings include:

Observation on February 3, 2016, at 9:45 am revealed ground floor lab (near West side windows) had an unsealed electrical circuit conduit for lab equipment that penetrated the fire rated floor assembly.

Interview with VPAS on February 3, 2016, at 9:45 am confirmed the unsealed floor penetration.

Based upon observation and interview, it was determined the facility failed to maintain doors protecting corridor openings in two of over 100 corridor doors.

Findings include:

1. Observation on February 2, 2016, at 12:18 pm revealed first floor Triage E.R. door is not smoke resistant (this is a split-access dutch door, that lacked an astragal).

Interview with VPAS on February 2, 2016, at 12:18 pm confirmed the corridor is not smoke resistant.

2. Observation on February 3, 2016, at 10:15 am revealed ground floor clean linen room corridor door lacked consistent positive latching with a self-closure.

Interview with VPAS on February 3, 2016, at 10:15 am confirmed the corridor door lacked consistent positive latching.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one hour.

Findings include:

Observation on February 2, 2016 at 9:15 am revealed the stairwell door (GS 12) from the basement assembly room lacked positive latching with the self-closer.

Interview with the Director of Environmental Services on February 2, 2016 at 9:15 am confirmed the stairwell door lacked positive latching with the self-closer.

Based on observation and interview, it was determined vertical openings between floors are not enclosed with construction having a fire resistive rating of one hour.

Findings include:

Observation on February 3, 2016 between 8:55 am and 9:30 am revealed the facility had unsealed vertical penetrations at the following locations:
a. The basement BASF1 had an unsealed penetration over the stairwell doors.
b. The basement elevator shaft had an unsealed penetrations from the electric cage into the elevator shaft.

Interview with the Director of Environmental Services on February 3, 2016 at 9:30 am confirmed the unsealed vertical penetrations.

Based upon observation and interview, it was determined the facility failed to maintain doors protecting hazardous openings in one of over twenty hazardous area doors.

Findings include:

Observation on February 2, 2016, at 10:20 am revealed second floor respiratory storage room door lacked positive latching with the self-closure.

Interview with VPAS on February 2, 2016, at 10:20 am confirmed the hazardous area door lacked positive latching.

Based upon observation and interview, the facility failed to maintain exit egress components with a fire rating of at least one hour, and provide a continuous path of egress, in three of seven exit stair towers.

Findings include:

Observation on February 2, 2016, between 8:45 am and 12:00 pm revealed the following stair tower concerns:
A. Fourth floor stair tower door to 4SF2 to Penthouse lacked consistent positive latching (8:45 am).
B. Third floor stair tower L3-FD12 had two unsealed penetrations (9:35 am).
C. First floor stair tower at entrance had two "cross walk" signs stored under the steps (12:00 pm).

Interview with VPAS on February 2, 2016, at 12:00 pm confirmed the above exit stair tower concerns.

Based upon observation and interview, the facility failed to maintain exit egress components to provide a continuous path of egress in one of over five exit discharges.

Findings include:

Observation on February 3, 2016, at 10:05 am revealed ground floor south wing exit to a public way had a concrete landing that is not solid, or free of projections, that could trip individuals.

Interview with VPAS on February 3, 2016, at 10:05 am confirmed the concrete landing was not level.

Based upon observation and interview the width of exit corridors are not clear and unobstructed in accordance with regulations on one of four floors.

Findings include:

Observation on February 2, 2016 at 9:30 am revealed the third floor rehab corridor had carts and were charging work stations on wheels in both sides of the corridor.

Interview with the Director of Environmental Services on February 2, 2016 at 9:30 am confirmed the facility had carts and work stations throughout the corridor.

Based on observation and interview, facility failed to maintain horizontal exits on one of one, two-hour fire barrier with another conforming building.

Findings include:

Observation on February 3, 2016, at 8:30 am revealed the two-hour fire barrier between M.R.I. building and Main building had multiple unsealed penetrations on both sides of fire barrier wall, above the ceiling tile.

Interview with Vice President of Ancillary Services on February 3, 2016, at 8:30 am confirmed the fire barrier had multiple unsealed penetrations.

Based on observation and interview, facility failed to maintain horizontal exits on one of one, two-hour fire barrier with another conforming building.

Findings include:

Observation on February 3, 2016, at 8:30 am revealed the two-hour fire barrier between Main building and M.R.I. building had multiple unsealed penetrations on both sides of fire barrier wall, above the ceiling tile.

Interview with VPAS on February 3, 2016, at 8:30 am confirmed the fire barrier had multiple unsealed penetrations.

Based upon interview, it was determined the facility failed to provide fire sprinkler coverage in elevator hoistways in four of four shafts containing combustible hydraulic fluids.

Findings include:

Interview with VPAS on February 3, 2015, at 11:30 am, (and later telephone conversation of February 8, 2016, at 12:05 pm) revealed four of four elevator shafts (containing combustible hydraulic fluids) within this component lacked fire sprinkler coverage.

Interview with VPAS on February 3, 2015, at 11:30 am confirmed the elevator shafts lacked fire sprinkler coverage.

Based upon interview, it was determined the facility failed to provide fire sprinkler coverage in elevator hoistways in one of one shafts containing combustible hydraulic fluids.

Findings include:

Interview with Vice President of Ancillary Services (VPAS) on February 3, 2015, at 11:30 am, (and later telephone conversation of February 8, 2016, at 12:05 pm) revealed one of one elevator shaft (containing combustible hydraulic fluids) within this component lacked fire sprinkler coverage.

Interview with VPAS on February 3, 2015, at 11:30 am confirmed the elevator shaft lacked fire sprinkler coverage.

Based on observation, documentation review, and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in three areas of the entire building.

Findings include:

Observation on February 2, 2016 at 1:05 pm revealed the sprinkler gauges in the fire pump room were not recalibrated or replaced as required at five year interval since January 2010.

Interview with the Director of Environmental Services on February 2, 2016 at 1:05 pm confirmed the sprinkler gauges were not recalibrated or replaced within the last five years.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition in four of seven building levels.

Findings include:

1. Observation on February 2, 2016, between 9:40 am and 1:10 pm revealed the following sprinkler concerns:
A. Third floor corridor above ceiling tile had a load of data wires on the fire sprinkler pipe between room 389 and smoke barrier 3NS3 (9:40 am).
B. Third floor equipment room 396A had data wires wrapped around the fire sprinkler head (9:50 am).
C. Second floor area above stair tower 2SF2 had a load of wires on the fire sprinkler pipe (10:15 am).
D. First floor Post Indicator Valve located outside receiving dock had sight glass that could not be read "open/closed" because the glass was painted over (1:10 pm).
E. First floor receiving stair tower had a sprinkler valve that lacked permanent identification as to which valve it is (1:10 pm).

Interview with VPAS on February 2, 2016, at 1:10 pm confirmed the above fire sprinkler concerns.

2. Observation on February 3, 2016, between 9:25 am and 11:15 am revealed the following sprinkler concerns:
A. Ground floor G24 storage had wire wrapped around the fire sprinkler head (9:25 am).
B. Ground floor linen chute discharge room had a sprinkler valve that lacked permanent identification as to which valve it is (10:20 am).
C. Ground floor G39C sprinkler valve lacked permanent identification as to which valve it is (11:15 am).

Interview with VPAS on February 3, 2016, at 11:15 am confirmed the above fire sprinkler concerns.

Based on observation and interview, the facility failed to ensure the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on two of seven building levels.

Findings include:

1. Observation on February 2, 2016, between 12:10 pm and 12:50 pm revealed the following fire extinguisher concerns:
A. 72 fire extinguishers on the first floor lacked an annual inspection for 2016.
B. First floor fire extinguisher in purchasing/receiving corridor is not protected from physical damage due to the Plexiglass removed from cabinet (12:50 pm).

Interview with VPAS on February 2, 2016, at 12:50 pm confirmed the above fire extinguisher concerns.

2. Observation on February 3, 2016, at 10:22 am revealed the ground floor fire extinguisher in the back of environmental services is not protected from physical damage due to the Plexiglass removed from cabinet.

Interview with VPAS on February 3, 2016, at 10:22 am confirmed the fire extinguisher cabinet lacked Plexiglass protection.

Based upon observation and interview, the facility failed to maintain the medical gas storage area in one of one main oxygen storage location.

Findings include:

Observation on February 2, 2016, at 1:00 pm revealed the facility failed to segregate oxygen cylinders between full and empty in the first floor main medical gas storage/manifold location.

Interview with VPAS on February 2, 2016, at 1:00 pm confirmed the oxygen cylinders were not segregated between full and empty.

Based upon observation and interview, the facility failed to maintain the piped-in medical gas system in one of one main medical gas manifold room.

Findings include:

Observation on February 2, 2016, at 12:55 pm revealed first floor main medical gas storage/manifold location had two unsecured nitrogen cylinders.

Interview with VPAS on February 2, 2016, at 12:55 pm confirmed the unsecured nitrogen cylinders.

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 in one of one Kitchen.

Findings include:

Observation on February 3, 2016, at 11:00 am revealed ground floor kitchen dish room had three unsecured carbon dioxide cylinders.

Interview with VPAS on February 3, 2016, at 11:00 am confirmed the unsecured cylinders.

Based upon observation and interview, it was determined the facility failed to maintain electrical wiring and/or equipment on four of seven building levels.

Findings include:

1. Observation on February 2, 2016, between 8:50 am and 12:35 pm revealed the following electrical concerns:
A. Fourth floor room 456 sleep lab had a C-pap machine plugged into a surge protector (8:50 am).
B. Fourth floor room 457 sleep lab had a C-pap machine plugged into a surge protector (8:53 am).
C. Fourth floor corridor between smoke barrier and 471 visitor lounge had an unsecured open junction box above the ceiling tile (9:00 am).
D. Second floor office 259 had a surge protector plugged into another surge protector (10:18 am).
E. First floor X-ray room 130 had a suspended surge protector hanging by the appliances plugged into it (12:35 pm).

Interview with VPAS on February 2, 2016, at 12:35 pm confirmed the above electrical concerns.

2. Observation on February 3, 2016, between 9:35 am and 9:50 am revealed the following electrical concerns:
A. Ground floor switchboard area had a refrigerator plugged into a surge protector (9:35 am).
B. Ground floor lab chem-freezer was plugged into an extension cord (9:50 am).

Interview with VPAS on February 3, 2016, at 9:50 am confirmed the above electrical concerns.