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145 NORTH 6TH STREET

READING, PA 19601

No Description Available

Tag No.: K0020

Based on observation and interview, it was determined the facility failed to protect vertical openings, through the floor assembly for one shaft, on one of six floors of the facility.

Findings include:

1. Observation on July 9, 2012, at 2:36 PM revealed the following unsealed penetrations, through the abandoned 4th Floor soiled linen chute:

a) Around a sprinkler pipe, located in the small storage closet;
b) An approximate one-inch hole above the chute access door.

Interview with the Director of Maintenance on July 9, 2012, at 2:36 PM confirmed the unsealed penetrations.

No Description Available

Tag No.: K0021

Based on observation and interview, it was determined the facility failed to ensure that doors to hazardous areas were only held open by devices arranged to automatically close upon activation of the sprinkler system, fire alarm system or local smoke detector in one location, on one of six floors of the facility.

Findings include:

1. Observation on July 9, 2012, at 10:10 AM revealed the door, to the 3rd Floor Soiled Utility Room, across from Patient Laundry, was held open with a red sharps container.

Interview with the Director of Maintenance on July 9, 2012, at 10:10 AM confirmed the door was held open by an unauthorized device.

No Description Available

Tag No.: K0025

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in one location, on one of one floor of the facility.

Findings include:

1. Observation on July 9, 2012, at 11:35 AM revealed unsealed smoke barrier penetrations located above ductwork, along the back wall and around various conduits and wires in the alcove, located in the 3rd Floor Treatment Planning Room.

Interview with the Director of Maintenance on July 9, 2012, at 11:35 AM confirmed the unsealed penetrations.

No Description Available

Tag No.: K0029

Based on observation and interview, it was determined the facility failed to ensure that hazardous areas were protected by smoke resistant construction with self-closing and positive latching doors in two locations, on two of six floors of the facility.

Findings include:

1. Observation on July 9, 2012, at 10:30 AM revealed the 3rd Floor West Therapist Office was used for the storage of combustible material and did not meet the requirements for a hazardous area enclosure.

Interview with the Director of Maintenance on July 9, 2012, at 10:30 AM confirmed the office was not designed for the storage of large quantities of combustibles.

2. Observation on July 9, 2012, at 2:52 PM revealed multiple penetrations in the 2nd Floor Medical Records Storage Room corridor double doors.

Interview with the Director of Maintenance on July 9, 2012, at 2:52 PM confirmed the door penetrations.

No Description Available

Tag No.: K0033

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of exit component enclosures in two locations, on two of six floors of the facility.

Findings include:

1. Observation on July 9, 2012, between 11:11 AM and 3:10 PM, revealed unsealed stair tower penetrations, in the following locations:

a) 11:11 AM, 3rd Floor Stair G drywall was not sealed to the underside of the concrete deck; drywall blow-out patches, used to seal penetrations, did not meet a two-hour fire resistance rating; the facility must verify the two-hour construction of the stair tower corner, at Conference Room 3328;
b) 3:10 PM, around a four-inch sprinkler pipe inside Stair A, located on the Basement Level.

Interview with the Director of Maintenance on July 9, 2012, at 3:10 PM confirmed the unsealed penetrations.

No Description Available

Tag No.: K0047

Based on observation and interview, it was determined the facility failed to ensure that doors, that are neither an exit nor a way of exit access which could be mistaken for an exit, are clearly marked with appropriate signage in one location, on one of six floors of the facility.

Findings include:

1. Observation on July 9, 2012, at 2:55 PM revealed the door leading to the Basement at the 1st Floor stair landing, located within Stair C, lacked appropriate "NO EXIT" signage.

Interview with the Director of Maintenance on July 9, 2012, at 2:55 PM confirmed the lack of signage.

No Description Available

Tag No.: K0048

Based on documentation review and interview, it was determined the facility failed to provide a written plan for the protection of all patients in the event of an emergency, in accordance with the regulations.

Findings include:

1. Review of documentation on July 9, 2012, between 1:15 PM and 2:00 PM, revealed the facility failed to provide a written fire safety plan, in accordance with the Life Safety Code, to all supervisory personnel. Interview with the Director of Nursing at 2:10 PM revealed that she was unaware of a written fire safety plan for Haven Behavioral Hospital.

Interview with the Director of Maintenance and Director of Nursing on July 9, 2012, at 2:10 PM confirmed the facility lacked an acceptable written fire safety plan.

No Description Available

Tag No.: K0075

Based on observation and interview, it was determined the facility failed to properly store trash collection receptacles greater than 32-gallon capacity in one location, on one of six floors of the facility.

Findings include:

1. Observation on July 9, 2012, at 10:05 AM revealed that two large trash bins were stored in the egress corridor, outside of a protected hazardous storage area, by the 3rd Floor Lunch Room/Art Therapy Room.

Interview with the Director of Maintenance on July 9, 2012, at 10:05 AM confirmed the trash bins were not properly stored.

No Description Available

Tag No.: K0147

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in two locations, on one of six floors.

Findings include:

1. Observation on July 9, 2012, at 10:00 AM revealed that two electrical junction boxes, used for duct smoke detector wiring, were missing cover plates, in 3rd Floor Mechanical/Electrical Room #1.

Interview with the Director of Maintenance on July 9, 2012, at 10:00 AM confirmed the missing cover plates.

2. Observation on July 9, 2012, at 10:30 AM revealed that a multi-outlet extension cord was used in the 3rd Floor West Therapist Office.

Interview with the Director of Maintenance on July 9, 2012, at 10:30 AM confirmed the improper use of the extension cord.