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DANVILLE STATE HOSPITAL
Roles Under a Waiver Declared by Secretary
Tag No.: E0026
Based on documentation review and interview it was determined the facility failed to address 1135 Waivers that may be issued by US Health and Human Services Secretary in the Emergency Response Plan for the facility.
Findings include:
Review of Emergency preparedness documentation on April 9, 2018, at 9:15 AM, revealed the facility failed to address 1135 Waivers that may be issued by US Health and Human Services Secretary, in the Emergency Response Plan.
Exit interview with facility administrator, facility representative #1 and maintenance representative #1 on April 11, 2018, between 10:15 AM and 10:30 AM, confirmed the facility failed to address Waivers that may be issued by US Health and Human Services Secretary in the Emergency Response Plan.
Building Construction Type and Height
Tag No.: K0161
Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors in this component.
Findings include:
1. Observation on April 10, 2018, between 8:15 AM and 1:45 PM, revealed the facility exceeds the maximum allowable story height for this type of construction.
Exit interview with facility administrator, facility representative #1 and maintenance representative #1 on April 11, 2018, between 10:15 AM and 10:30 AM, confirmed the facility exceeds the maximum allowable story height for this type of construction.
Vertical Openings - Enclosure
Tag No.: K0311
Based on observation and interview, it was determined the facility failed to construct and maintain vertical enclosures, affecting four of four floors in this component.
Findings include:
1. Observation on April 10, 2018, between 8:15 AM and 1:45 PM, revealed vertical enclosures to include exit stair towers, elevator shafts, dumbwaiter shafts and mechanical chases, did not have the required 2-hour fire resistance rating.
Exit interview with facility administrator, facility representative #1 and maintenance representative #1 on April 11, 2018, between 10:15 AM and 10:30 AM, confirmed vertical enclosures did not have the required fire resistance rating.
Sprinkler System - Installation
Tag No.: K0351
Based on observation and interview, it was determined the facility failed to provide complete sprinkler coverage, affecting one of fifteen smoke compartments in this component.
Findings include:
1. Observation on April 10, 2018, at 8:56 AM, revealed the unit 222 consumer telephone enclosures lacked sprinkler coverage.
Exit interview with facility administrator, facility representative #1 and maintenance representative #1 on April 11, 2018, between 10:15 AM and 10:30 AM, confirmed the unit 222 phone enclosures obstructed the available sprinkler coverage.
Corridor - Doors
Tag No.: K0363
Based on observation and interview, it was determined the facility failed to maintain one of over 251 corridor doors in this component.
Findings include:
1. Observation on April 10, 2018, at 9:16 AM, revealed the Unit 212 med room had a dutch door that lacked a required rabbet, bevel or astragal.
Exit interview with facility administrator, facility representative #1 and maintenance representative #1 on April 11, 2018, between 10:15 AM and 10:30 AM, confirmed the gap between the upper and lower half of the unit 212 med room dutch door was not sealed.