HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating, of common walls to a non-conforming building, in one location.

Findings include:

1. Observation on February 14, 2012, at 8:50 AM revealed the common wall, separating the ASC from the link to the MOB, was not sealed to the deck, on the link side.

Interview with the Director of Facilities Management on February 14, 2012, at 8:50 AM confirmed the unsealed area.

Based on observation and interview, it was determined the facility failed to maintain corridor doors at four locations, on four of ten floors.

Findings include:

1. Observation of corridor doors, on February 13, 2012, revealed the following:

a. 10:30 AM, the double corridor door to the Basement Central Supply, the inactive door was not latched, leaving both doors with no positive latching;

Interview with the Director of Facilities Management on February 13, 2012, at 10:30 AM confirmed the doors would not latch.

b. 1:40 PM, the corridor door to the Dining Room, on the fifth floor, would not close and latch.

Interview with the Maintenance Supervisor, on February 13, 2012, at 1:40 PM confirmed the corridor door would not close and latch.

2. Observation of corridor doors, on February 14, 2012, revealed the following:

a. 11:40 AM, the corridor door to the Respiratory Lounge, on the third floor, was equipped with a straight edge dead bolt lock;

b. 11:45 AM, the corridor door to the Respiratory Directors Office, on the third floor, was equipped with a straight edge dead bolt lock;

c. 11:50 AM, the corridor door to the Pulmonary Function Lab, on the third floor, was equipped with a straight edge dead bolt lock;

Interview with the Maintenance Supervisor, on February 14, 2012, at 11:50 AM confirmed the corridor doors were equipped with a straight edge dead bolt locks.

d. 10:25 AM, the double corridor doors, to the 2nd Floor Mechanical Room 2A, needed a coordinator adjustment to properly close and latch;
Interview with the Director of Facilities Management on February 13, 2012, at 10:25 AM confirmed the doors would not close and latch.

3. Observation on February 14, 2012, at 11:20 AM revealed the double corridor doors, to the 2nd Floor Kitchen, by the Dietary Clerks Office, required a closure adjustment to properly close and latch.

Interview with the Director of Facilities Management on February 14, 2012, at 11:20 AM confirmed the doors would not close and latch.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistive rating of vertical shafts at three locations, on three of ten floors.

Findings include:

1. Observation on February 13, 2012, of vertical shafts revealed the following:

a. 0:35 AM: there were unsealed penetrations to two shaft walls, around three sets of wires and along a vertical crack, in the shaft next to elevator #8, on the seventh floor;

b. 1:45 PM: there were unsealed penetrations around conduits, over the door, and a conduit in the corner is sealed with unapproved foam, in the shaft next to elevator #8, on the fifth floor.

Interview with the Maintenance Supervisor on February 13, 2012, at 1:45 PM confirmed the unsealed shaft penetrations.

2. Observation on February 14, at 11:30 AM, revealed there was an unrated shaft door, in the connecting corridor, between the A / B Buildings.

Interview with the Maintenance Supervisor on February 14, at 11:30 AM confirmed the unrated shaft door.

Based on observation and interview, it was determined the facility failed to provide properly sized smoke compartments in accordance with the regulations throughout the facility.

Findings include:

1. Observation on February 13 - 14, 2012, during the course of the two-day survey, revealed that smoke compartments, throughout the facility, exceeded 22,500 square feet.

Interview with the Director of Facility Maintenance and the Maintenance Supervisor on February 14, 2012, at 2:00 PM confirmed the extended smoke compartments and identified that the facility has an acceptable FSES reviewed on February 13 - 14, 2012, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in five locations, on two of ten floors.

Findings include:

1. Observation on February 13, 2012, between 2:45 PM and 3:05 PM, revealed the following unsealed smoke barrier penetrations on the 1st Floor:

a) 2:45 PM, Janitor Closet in A-Building corridor at a 4-inch PVC pipe without a collar;
b) 3:05 PM, Restroom outside Physical Therapy, various penetrations on 3 of 4 walls.

Interview with the Director of Facilities Management on February 13, 2012, at 3:05 PM confirmed the unsealed penetrations.

2. Observation on February 14, 2012, between 10:40 AM and 12:55 PM, revealed the following unsealed smoke barrier penetrations on the 2nd Floor:

a) 10:40 AM, Mechanical Room 2A corridor, at the doorway to the Lab, above ceiling the corner, was missing wallboard and masonry block;
b) 12:50 PM, Nurses' Station & Elevator double corridor doors, has an unsealed smoke penetration around grey data wires;
b) 12:55 PM, TRU double corridor doors, by Elevators 11 &12 around white, blue and orange data wires.

Interview with the Director of Facilities Management on February 14, 2012, at 12:55 PM confirmed the unsealed penetrations.

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

Findings include:

1. Observation on February 14, 2012, between 9:00 AM and 9:20 AM, revealed the following unsealed smoke barrier penetrations:

a) 9:20 AM, around data wires, over the door, between the Anesthesia Office and the Anesthesia Work Room;
b) 9:15 AM, around pipes and drywall tape falling off, in Recovery Room 16;
c) 9:20 AM, around data wires, over the double doors to the OR's, next to Recovery Room 16.

Interview with the Director of Facilities Management on February 14, 2012, at 9:30 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of a smoke barrier door opening, in two locations.

Findings include:

1. Observation on February 13, 2012, at 11:55 AM revealed the smoke barrier door, to Basement Treatment Room 4, lacked a self-closing device.

Interview with the Director of Facilities Management on February 13, 2012, at 11:55 AM confirmed the lack of a self-closure.

2. Observation on February 14, 2012, at 11:05 AM revealed the double corridor smoke barrier doors, on the 2nd Floor outside Dietary, required a coordinator adjustment to properly close and latch in its frame.

Interview with the Director of Facilities Management on February 14, 2012, at 11:05 AM confirmed the needed adjustment.

Based on observation and interview, it was determined the facility failed to ensure that hazardous areas were protected by one-hour fire-rated or smoke-resisted construction with self-closing and positive latching doors at four locations on three of ten floors.

Findings include:

1. Observation on February 13, 2012, at 11:25 AM revealed the door, to the Oxygen Storage Room on the seventh floor, would not self close and latch.

Interview with the Maintenance Supervisor on February 13, 2012 at 11:25 AM confirmed the door would not self close and latch.

2. Observation on February 13, 2012, at 1:25 PM revealed the door, to the Computer Storage Room on the 1st Floor, had the closure disconnected and had multi-penetrations, on all four walls.

Interview with the Director of Facilities Management on February 13, 2012, at 1:25 PM confirmed the disconnect closure and the penetrations.

3. Observation on February 13, 2012, at 2:00 PM revealed the door, to the Gift Shop Storage Room on the 1st Floor, had the closure disconnected and 2 of 4 walls do not extend to the deck above.

Interview with the Director of Facilities Management on February 13, 2012, at 2:00 PM confirmed the disconnect closure and the incomplete walls.

4. Observation on February 14, 2012, at 10:35 AM revealed unsealed penetrations around data wires and a conduit, over the corridor double doors to the 2nd Floor Mechanical Room 2A.

Interview with the Director of Facilities Management on February 14, 2012, at 10:35 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of four exit component enclosures, on four of ten floors of the facility.

1. Observation on February 13, 2012, of stair tower components revealed the following:

a. 11:27 AM, the door, to stair tower 1-C on the seventh floor, would not self close and latch;

b. 1:10 PM, the door, to stair tower 3-A on the fifth floor, would not self close and latch.

Interview with the Maintenance Supervisor on February 13, 2012 at 1:10 PM confirmed the two doors would not self close and latch.

2. Observation on February 13, 2012, at 2:30 PM revealed the corridor side of the B-Wing, 1st Floor Stairtower #2, the face of the masonry block wall had been removed from above the ceiling to the floor (Approx. 12 inches wide) to run supply and vent lines. This negates the 2-hour rating that is need for this Stairtower.

Interview with the Director of Facilities Management on February 13, 2012, at 2:30 PM confirmed the missing block face.

3. Observation on February 14, 2012, at 10:15 AM revealed there was an unsealed penetration, in the 1st Floor Physical Therapy Treatment Room, over the door, around grey wires.

Interview with the Director of Facilities Management on February 14, 2012, at 10:15 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits were not used for any purpose that has the potential to interfere with egress on one instance, on the 1st floor of the facility.

Findings include:

1. Observation on February 14, 2012, at 10:10 AM revealed that a closet for storage, had been built under the stair run, on the 1st Floor Physical Therapy Stairwell.

Interview with the Director of Facilities Management on February 14, 2012, at 10:10 AM confirmed the closet.

Based on observation and interview, it was determined the facility failed to ensure that access to exits were clearly defined with directional signs at two locations, on two of ten floors.

Findings include:

1. Observation on February 13, 2012, at 11:20 AM revealed there is an exit sign directing egress onto a roof top, with no way to get down, in the A Building Mechanical Room, on the fifth floor. There are two other existing exits out of this area.

Interview with the Maintenance Supervisor on February 13, 2012 at 11:20 AM confirmed the sign led to the roof top.

2. Observation on February 13, 2012, at 1:50 PM revealed the exit sign, in the fifth floor corridor, needs to be relocated, so it directs egress into the #3 stair tower.

Interview with the Maintenance Supervisor on February 13, 2012 at 1:50 PM confirmed the sign needs relocated.

Based on review of documentation and interview, it was determined the facility failed to conduct fire drills at random times for the second and third shifts, during the last twelve months.
Findings include:
1. Review of documentation on February 13, 2012, at 9:40 AM revealed that fire drills were not conducted at random times for the second and third shifts, during the last twelve months.
Interview with the Director of Facility Maintenance on February 13, 2012, at 9:40 AM confirmed the fire drills were not conducted at random times.

Based on observation and interview, the facility failed to ensure that the sprinkler system provided complete coverage, for one area of the building.

Findings include:

1. Observation on February 14, 2012, at 11:10 AM revealed the crawl space area, on the 2nd Floor back of B Building, lacked sprinkler protection. Within this area combustible items were being stored.

Interview with the Director of Facilities Management on February 14, 2012, at 11:10 AM confirmed the storage and lack of sprinkler protection.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system at nine locations, on four of ten floors.

Findings include:
1. Observation of sprinkler system components on February 13, 2012, revealed the following:

a. 1:25 PM, there was storage within 18 inches of a sprinkler head, in the 1st Floor Computer Storage Room, in the Nursing Services Office.

Interview with the Director of Facilities Management on February 13, 2012, at 1:25 PM confirmed the storage.

2. Observation of sprinkler system components on February 14, 2012, revealed the following:

a. 9:25 AM, there was storage within 18 inches of a sprinkler head, in a Labor and Delivery corridor closet, on the fourth floor;

b. 9:35 AM, there was storage within 18 inches of a sprinkler head, in a Labor and Delivery Anesthesia closet, on the fourth floor;

c. 9:55 AM, there was a surface-mounted light fixture, within 12 inches of a sprinkler head, in Room 405, on the fourth floor, which extended below the deflector head;

d. 12:50 PM, there was a missing escutcheon plate, in the CT Dressing Room, on the third floor;

e. 1:05 PM, there was storage within 18 inches of a sprinkler head, in an X-Ray Closet, by Changing Room #4, on the third floor;

Interview with the Maintenance Supervisor on February 14, 2012, at 1:05 PM confirmed the obstructed sprinkler heads and the missing escutcheon plate.

f. 10:45 AM, there were data wires tied to or supported by the sprinkler system, in the 2nd Floor corridor, between the Lab and the Lab Director Office;


Interview with the Director of Facilities Management on February 14, 2012, at 10:45 PM confirmed the items supported by the sprinkler system.

g. 11:25 AM, there were surface-mounted light fixtures, within 12 inches of the sprinkler head, which extended below the deflector of the head, 1 at the Cold Production Area and 2 in the Dishroom of the 2nd Floor Kitchen;

Interview with the Director of Facilities Management on February 14, 2012, at 11:25 PM confirmed the obstructed sprinkler heads.

h. 12:50 PM, 2nd Floor at Nurses' Station & Elevators, there were grey data cables being supported by sprinkler piping;

Interview with the Director of Facilities Management on February 14, 2012, at 12:50 PM confirmed the supported cables.

Based on observation and interview, it was determined that the facility failed to ensure that fire dampers in the Heating, Ventilating, and Air Conditioning (HVAC) system were properly maintained, in one area of the facility.

Findings include:

1. Observation on February 13, 2012, at 2:00 PM revealed the 1st Floor Gift Shop Storage Room had a plenum ceiling cavity. This cavity was also shared with an adjoining Office and a Vending Area, that is open to the Main Corridor and Entrance Lobby.

Interview with the Director of Facilities Management on February 13, 2012, at 2:00 PM confirmed the plenum ceiling.

Based on observation and interview, it was determined the facility was using a portable space heating device, at one location.

Findings include:

1. Observation on February 14, 2012, at 9:05 AM revealed there was a portable space heater being used in the Utilization Review Office, on the fifth floor. The facility could not verify the temperature range of the heating element.

Interview with the Maintenance Supervisor on February 14, 2012, at 9:05 AM confirmed the space heater was in use.

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

Findings include:

1. Observation on February 14, 2012, at 10:30 AM revealed the storage of one four-wheel flat and a one cubic-yard wheeled trash container, on the 2nd Floor outside Mechanical Room 2A and the Lab.

Interview with the Director of Facilities Management on February 14, 2012, at 10:30 AM confirmed the storage.

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

Findings include:

1. Observation on February 13 - 14, 2012, during the course of the two-day survey, revealed the facility failed to supply an accurate set of portable floor plans for the Life Safety Survey, showing all common walls and smoke walls, throughout the Main Building.

Interview with the Director of Facility Maintenance on February 14, 2012, at 1:45 PM confirmed the floor plans were not accurate.

Based on observation and interview, the facility failed to maintain electrical wiring and
proper use of equipment, surge protectors, receptacle multipliers and extension cords at nine locations on four of ten floors.

Findings include:

1. Observation of the electrical wiring system on February 13, 2012, revealed the following:

a. 10:10 AM, an extension cord was being used to power a chemical feed pump, in the Upper Penthouse;

b. 11:20 AM, extension cords plugged into surge suppressors were being used to power medical equipment, in Operating Rooms #2 and #3, on the seventh floor;

Interview with the Maintenance Supervisor on February 13, 2012, at 11:20 AM confirmed the use of the extension cords and power taps.

c. 1:30 PM, a 6-way receptacle multiplier was being used in a office, inside the 1st Floor Nurses' Services Area;

Interview with the Director of Facilities Management on February 13, 2012, at 1:30 PM confirmed the use of the 6-way receptacle multiplier.

d. 2:20 PM, temporary wiring was running, from a junction box, across the ceiling and into a wall of the Chapel, by the Lobby Piano;

Interview with the Director of Facilities Management on February 13, 2012, at 2:20 PM confirmed the temporary wiring.

e. 2:55 PM, a surge suppressor was being used to power a refrigerator and a coffee maker, in the Credit and Collection Off ice, on the 1st Floor.

Interview with the Director of Facilities Management on February 13, 2012, at 2:55 PM confirmed the misuse of a surge suppressor.

2. Observation of the electrical wiring system on February 14, 2012, revealed the following:

a. 11:00 PM, in the Pharmacy, on the 2nd Floor;
(1) a surge suppressor was being used to power a toaster, toaster oven and a microwave;
(2) a 3-way receptacle multiplier was being used on the counter, by the labels;
(3) surge suppressors were piggy-backed and plugged into a receptacle multiplier, to supply power a refrigerator and a Pyxis Medication Station.

Interview with the Director of Facilities Management on February 14, 2012, at 11:00 AM confirmed the misuse of surge suppressors and a receptacle multiplier.

b. 12:50 PM, Occupational Therapy Kitchen, on the 2nd Floor, revealed there was an electrical junction box that lacked a cover plate and exposed wires, which were not properly terminated, in an electrical junction box.

Interview with the Director of Facilities Management on February 14, 2012, at 12:50 PM confirmed the missing cover and exposed unterminated wiring.

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating, of common walls to a non-conforming building, in one location.

Findings include:

1. Observation on February 14, 2012, at 8:50 AM revealed the common wall, separating the ASC from the link to the MOB, was not sealed to the deck, on the link side.

Interview with the Director of Facilities Management on February 14, 2012, at 8:50 AM confirmed the unsealed area.

Based on observation and interview, it was determined the facility failed to maintain corridor doors at four locations, on four of ten floors.

Findings include:

1. Observation of corridor doors, on February 13, 2012, revealed the following:

a. 10:30 AM, the double corridor door to the Basement Central Supply, the inactive door was not latched, leaving both doors with no positive latching;

Interview with the Director of Facilities Management on February 13, 2012, at 10:30 AM confirmed the doors would not latch.

b. 1:40 PM, the corridor door to the Dining Room, on the fifth floor, would not close and latch.

Interview with the Maintenance Supervisor, on February 13, 2012, at 1:40 PM confirmed the corridor door would not close and latch.

2. Observation of corridor doors, on February 14, 2012, revealed the following:

a. 11:40 AM, the corridor door to the Respiratory Lounge, on the third floor, was equipped with a straight edge dead bolt lock;

b. 11:45 AM, the corridor door to the Respiratory Directors Office, on the third floor, was equipped with a straight edge dead bolt lock;

c. 11:50 AM, the corridor door to the Pulmonary Function Lab, on the third floor, was equipped with a straight edge dead bolt lock;

Interview with the Maintenance Supervisor, on February 14, 2012, at 11:50 AM confirmed the corridor doors were equipped with a straight edge dead bolt locks.

d. 10:25 AM, the double corridor doors, to the 2nd Floor Mechanical Room 2A, needed a coordinator adjustment to properly close and latch;
Interview with the Director of Facilities Management on February 13, 2012, at 10:25 AM confirmed the doors would not close and latch.

3. Observation on February 14, 2012, at 11:20 AM revealed the double corridor doors, to the 2nd Floor Kitchen, by the Dietary Clerks Office, required a closure adjustment to properly close and latch.

Interview with the Director of Facilities Management on February 14, 2012, at 11:20 AM confirmed the doors would not close and latch.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistive rating of vertical shafts at three locations, on three of ten floors.

Findings include:

1. Observation on February 13, 2012, of vertical shafts revealed the following:

a. 0:35 AM: there were unsealed penetrations to two shaft walls, around three sets of wires and along a vertical crack, in the shaft next to elevator #8, on the seventh floor;

b. 1:45 PM: there were unsealed penetrations around conduits, over the door, and a conduit in the corner is sealed with unapproved foam, in the shaft next to elevator #8, on the fifth floor.

Interview with the Maintenance Supervisor on February 13, 2012, at 1:45 PM confirmed the unsealed shaft penetrations.

2. Observation on February 14, at 11:30 AM, revealed there was an unrated shaft door, in the connecting corridor, between the A / B Buildings.

Interview with the Maintenance Supervisor on February 14, at 11:30 AM confirmed the unrated shaft door.

Based on observation and interview, it was determined the facility failed to provide properly sized smoke compartments in accordance with the regulations throughout the facility.

Findings include:

1. Observation on February 13 - 14, 2012, during the course of the two-day survey, revealed that smoke compartments, throughout the facility, exceeded 22,500 square feet.

Interview with the Director of Facility Maintenance and the Maintenance Supervisor on February 14, 2012, at 2:00 PM confirmed the extended smoke compartments and identified that the facility has an acceptable FSES reviewed on February 13 - 14, 2012, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of smoke barrier walls in five locations, on two of ten floors.

Findings include:

1. Observation on February 13, 2012, between 2:45 PM and 3:05 PM, revealed the following unsealed smoke barrier penetrations on the 1st Floor:

a) 2:45 PM, Janitor Closet in A-Building corridor at a 4-inch PVC pipe without a collar;
b) 3:05 PM, Restroom outside Physical Therapy, various penetrations on 3 of 4 walls.

Interview with the Director of Facilities Management on February 13, 2012, at 3:05 PM confirmed the unsealed penetrations.

2. Observation on February 14, 2012, between 10:40 AM and 12:55 PM, revealed the following unsealed smoke barrier penetrations on the 2nd Floor:

a) 10:40 AM, Mechanical Room 2A corridor, at the doorway to the Lab, above ceiling the corner, was missing wallboard and masonry block;
b) 12:50 PM, Nurses' Station & Elevator double corridor doors, has an unsealed smoke penetration around grey data wires;
b) 12:55 PM, TRU double corridor doors, by Elevators 11 &12 around white, blue and orange data wires.

Interview with the Director of Facilities Management on February 14, 2012, at 12:55 PM confirmed the unsealed penetrations.

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

Findings include:

1. Observation on February 14, 2012, between 9:00 AM and 9:20 AM, revealed the following unsealed smoke barrier penetrations:

a) 9:20 AM, around data wires, over the door, between the Anesthesia Office and the Anesthesia Work Room;
b) 9:15 AM, around pipes and drywall tape falling off, in Recovery Room 16;
c) 9:20 AM, around data wires, over the double doors to the OR's, next to Recovery Room 16.

Interview with the Director of Facilities Management on February 14, 2012, at 9:30 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of a smoke barrier door opening, in two locations.

Findings include:

1. Observation on February 13, 2012, at 11:55 AM revealed the smoke barrier door, to Basement Treatment Room 4, lacked a self-closing device.

Interview with the Director of Facilities Management on February 13, 2012, at 11:55 AM confirmed the lack of a self-closure.

2. Observation on February 14, 2012, at 11:05 AM revealed the double corridor smoke barrier doors, on the 2nd Floor outside Dietary, required a coordinator adjustment to properly close and latch in its frame.

Interview with the Director of Facilities Management on February 14, 2012, at 11:05 AM confirmed the needed adjustment.

Based on observation and interview, it was determined the facility failed to ensure that hazardous areas were protected by one-hour fire-rated or smoke-resisted construction with self-closing and positive latching doors at four locations on three of ten floors.

Findings include:

1. Observation on February 13, 2012, at 11:25 AM revealed the door, to the Oxygen Storage Room on the seventh floor, would not self close and latch.

Interview with the Maintenance Supervisor on February 13, 2012 at 11:25 AM confirmed the door would not self close and latch.

2. Observation on February 13, 2012, at 1:25 PM revealed the door, to the Computer Storage Room on the 1st Floor, had the closure disconnected and had multi-penetrations, on all four walls.

Interview with the Director of Facilities Management on February 13, 2012, at 1:25 PM confirmed the disconnect closure and the penetrations.

3. Observation on February 13, 2012, at 2:00 PM revealed the door, to the Gift Shop Storage Room on the 1st Floor, had the closure disconnected and 2 of 4 walls do not extend to the deck above.

Interview with the Director of Facilities Management on February 13, 2012, at 2:00 PM confirmed the disconnect closure and the incomplete walls.

4. Observation on February 14, 2012, at 10:35 AM revealed unsealed penetrations around data wires and a conduit, over the corridor double doors to the 2nd Floor Mechanical Room 2A.

Interview with the Director of Facilities Management on February 14, 2012, at 10:35 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of four exit component enclosures, on four of ten floors of the facility.

1. Observation on February 13, 2012, of stair tower components revealed the following:

a. 11:27 AM, the door, to stair tower 1-C on the seventh floor, would not self close and latch;

b. 1:10 PM, the door, to stair tower 3-A on the fifth floor, would not self close and latch.

Interview with the Maintenance Supervisor on February 13, 2012 at 1:10 PM confirmed the two doors would not self close and latch.

2. Observation on February 13, 2012, at 2:30 PM revealed the corridor side of the B-Wing, 1st Floor Stairtower #2, the face of the masonry block wall had been removed from above the ceiling to the floor (Approx. 12 inches wide) to run supply and vent lines. This negates the 2-hour rating that is need for this Stairtower.

Interview with the Director of Facilities Management on February 13, 2012, at 2:30 PM confirmed the missing block face.

3. Observation on February 14, 2012, at 10:15 AM revealed there was an unsealed penetration, in the 1st Floor Physical Therapy Treatment Room, over the door, around grey wires.

Interview with the Director of Facilities Management on February 14, 2012, at 10:15 AM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits were not used for any purpose that has the potential to interfere with egress on one instance, on the 1st floor of the facility.

Findings include:

1. Observation on February 14, 2012, at 10:10 AM revealed that a closet for storage, had been built under the stair run, on the 1st Floor Physical Therapy Stairwell.

Interview with the Director of Facilities Management on February 14, 2012, at 10:10 AM confirmed the closet.

Based on observation and interview, it was determined the facility failed to ensure that access to exits were clearly defined with directional signs at two locations, on two of ten floors.

Findings include:

1. Observation on February 13, 2012, at 11:20 AM revealed there is an exit sign directing egress onto a roof top, with no way to get down, in the A Building Mechanical Room, on the fifth floor. There are two other existing exits out of this area.

Interview with the Maintenance Supervisor on February 13, 2012 at 11:20 AM confirmed the sign led to the roof top.

2. Observation on February 13, 2012, at 1:50 PM revealed the exit sign, in the fifth floor corridor, needs to be relocated, so it directs egress into the #3 stair tower.

Interview with the Maintenance Supervisor on February 13, 2012 at 1:50 PM confirmed the sign needs relocated.

Based on review of documentation and interview, it was determined the facility failed to conduct fire drills at random times for the second and third shifts, during the last twelve months.
Findings include:
1. Review of documentation on February 13, 2012, at 9:40 AM revealed that fire drills were not conducted at random times for the second and third shifts, during the last twelve months.
Interview with the Director of Facility Maintenance on February 13, 2012, at 9:40 AM confirmed the fire drills were not conducted at random times.

Based on observation and interview, the facility failed to ensure that the sprinkler system provided complete coverage, for one area of the building.

Findings include:

1. Observation on February 14, 2012, at 11:10 AM revealed the crawl space area, on the 2nd Floor back of B Building, lacked sprinkler protection. Within this area combustible items were being stored.

Interview with the Director of Facilities Management on February 14, 2012, at 11:10 AM confirmed the storage and lack of sprinkler protection.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system at nine locations, on four of ten floors.

Findings include:
1. Observation of sprinkler system components on February 13, 2012, revealed the following:

a. 1:25 PM, there was storage within 18 inches of a sprinkler head, in the 1st Floor Computer Storage Room, in the Nursing Services Office.

Interview with the Director of Facilities Management on February 13, 2012, at 1:25 PM confirmed the storage.

2. Observation of sprinkler system components on February 14, 2012, revealed the following:

a. 9:25 AM, there was storage within 18 inches of a sprinkler head, in a Labor and Delivery corridor closet, on the fourth floor;

b. 9:35 AM, there was storage within 18 inches of a sprinkler head, in a Labor and Delivery Anesthesia closet, on the fourth floor;

c. 9:55 AM, there was a surface-mounted light fixture, within 12 inches of a sprinkler head, in Room 405, on the fourth floor, which extended below the deflector head;

d. 12:50 PM, there was a missing escutcheon plate, in the CT Dressing Room, on the third floor;

e. 1:05 PM, there was storage within 18 inches of a sprinkler head, in an X-Ray Closet, by Changing Room #4, on the third floor;

Interview with the Maintenance Supervisor on February 14, 2012, at 1:05 PM confirmed the obstructed sprinkler heads and the missing escutcheon plate.

f. 10:45 AM, there were data wires tied to or supported by the sprinkler system, in the 2nd Floor corridor, between the Lab and the Lab Director Office;


Interview with the Director of Facilities Management on February 14, 2012, at 10:45 PM confirmed the items supported by the sprinkler system.

g. 11:25 AM, there were surface-mounted light fixtures, within 12 inches of the sprinkler head, which extended below the deflector of the head, 1 at the Cold Production Area and 2 in the Dishroom of the 2nd Floor Kitchen;

Interview with the Director of Facilities Management on February 14, 2012, at 11:25 PM confirmed the obstructed sprinkler heads.

h. 12:50 PM, 2nd Floor at Nurses' Station & Elevators, there were grey data cables being supported by sprinkler piping;

Interview with the Director of Facilities Management on February 14, 2012, at 12:50 PM confirmed the supported cables.

Based on observation and interview, it was determined that the facility failed to ensure that fire dampers in the Heating, Ventilating, and Air Conditioning (HVAC) system were properly maintained, in one area of the facility.

Findings include:

1. Observation on February 13, 2012, at 2:00 PM revealed the 1st Floor Gift Shop Storage Room had a plenum ceiling cavity. This cavity was also shared with an adjoining Office and a Vending Area, that is open to the Main Corridor and Entrance Lobby.

Interview with the Director of Facilities Management on February 13, 2012, at 2:00 PM confirmed the plenum ceiling.

Based on observation and interview, it was determined the facility was using a portable space heating device, at one location.

Findings include:

1. Observation on February 14, 2012, at 9:05 AM revealed there was a portable space heater being used in the Utilization Review Office, on the fifth floor. The facility could not verify the temperature range of the heating element.

Interview with the Maintenance Supervisor on February 14, 2012, at 9:05 AM confirmed the space heater was in use.

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

Findings include:

1. Observation on February 14, 2012, at 10:30 AM revealed the storage of one four-wheel flat and a one cubic-yard wheeled trash container, on the 2nd Floor outside Mechanical Room 2A and the Lab.

Interview with the Director of Facilities Management on February 14, 2012, at 10:30 AM confirmed the storage.

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

Findings include:

1. Observation on February 13 - 14, 2012, during the course of the two-day survey, revealed the facility failed to supply an accurate set of portable floor plans for the Life Safety Survey, showing all common walls and smoke walls, throughout the Main Building.

Interview with the Director of Facility Maintenance on February 14, 2012, at 1:45 PM confirmed the floor plans were not accurate.

Based on observation and interview, the facility failed to maintain electrical wiring and
proper use of equipment, surge protectors, receptacle multipliers and extension cords at nine locations on four of ten floors.

Findings include:

1. Observation of the electrical wiring system on February 13, 2012, revealed the following:

a. 10:10 AM, an extension cord was being used to power a chemical feed pump, in the Upper Penthouse;

b. 11:20 AM, extension cords plugged into surge suppressors were being used to power medical equipment, in Operating Rooms #2 and #3, on the seventh floor;

Interview with the Maintenance Supervisor on February 13, 2012, at 11:20 AM confirmed the use of the extension cords and power taps.

c. 1:30 PM, a 6-way receptacle multiplier was being used in a office, inside the 1st Floor Nurses' Services Area;

Interview with the Director of Facilities Management on February 13, 2012, at 1:30 PM confirmed the use of the 6-way receptacle multiplier.

d. 2:20 PM, temporary wiring was running, from a junction box, across the ceiling and into a wall of the Chapel, by the Lobby Piano;

Interview with the Director of Facilities Management on February 13, 2012, at 2:20 PM confirmed the temporary wiring.

e. 2:55 PM, a surge suppressor was being used to power a refrigerator and a coffee maker, in the Credit and Collection Off ice, on the 1st Floor.

Interview with the Director of Facilities Management on February 13, 2012, at 2:55 PM confirmed the misuse of a surge suppressor.

2. Observation of the electrical wiring system on February 14, 2012, revealed the following:

a. 11:00 PM, in the Pharmacy, on the 2nd Floor;
(1) a surge suppressor was being used to power a toaster, toaster oven and a microwave;
(2) a 3-way receptacle multiplier was being used on the counter, by the labels;
(3) surge suppressors were piggy-backed and plugged into a receptacle multiplier, to supply power a refrigerator and a Pyxis Medication Station.

Interview with the Director of Facilities Management on February 14, 2012, at 11:00 AM confirmed the misuse of surge suppressors and a receptacle multiplier.

b. 12:50 PM, Occupational Therapy Kitchen, on the 2nd Floor, revealed there was an electrical junction box that lacked a cover plate and exposed wires, which were not properly terminated, in an electrical junction box.

Interview with the Director of Facilities Management on February 14, 2012, at 12:50 PM confirmed the missing cover and exposed unterminated wiring.