HospitalInspections.org

K 012

Based on observation and interview, it was determined that the building construction type and height does not meet regulations on three of four building levels.

Findings include:

Observation on February 28, 2012 between 10:00 a.m. and 11:30 a.m. revealed the following floor/ceiling assemblies are not adequately sealed:
A. Basement room 12 has a hole in the ceiling (10:00 a.m.).
B. First floor closet to the left of S. R. T. P.(sexual responsibility and treatment program) administrative offices has a hole in the ceiling (10:05 a.m.).
C. First floor S. R. T. P. administrative offices closet has a hole around ceiling light (10:10 a.m.).
D. First floor vending machine room across from 112 has an unsealed floor penetration (11:30 a.m.).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:30 a.m. confirmed the unsealed floor/ceiling assembly is not maintained.

K 017

Based upon observation and interview, the corridor walls do not meet the requirements of the regulations on one of five building levels.

Findings include:

Observation on February 27, 2012 at 1:15 pm revealed third floor corridor walls at Doctor Office Ward #3 has fusible link fire dampers installed throughout in the corridor walls above the ceiling tile. Facility is using corridors as a plenum-rated assembly. The fire dampers in the corridor walls would not resist the passage of smoke.

Interview with Chief Operating Officer on February 27, 2012 at 1:15 pm confirmed the corridor fire dampers do not maintain a smoke resistant corridor wall.

K 018


Based upon observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, nor smoke resistant, as per regulations in one of three floors.

Findings include:

Observation on February 28, 2012 at 3:40 p.m. revealed that room 0025B corridor door was being held open with an unapproved hold-open device (wedge).

Interview with the Facility Maintenance Manager on February 28, 2012 at 3:40 p.m. confirmed the corridor door was being held open with a wedge.

K 020

Based upon observation and interview, it was determined that the vertical openings between floors are not enclosed with construction having a fire resistive rating of 1 hour on one of three floors.

Findings include:

Observation on February 28, 2012 between 3:30 pm and 3:40 pm revealed the facility had unsealed pipe chase shaft penetration at the following locations:
1. Basement pipe chase 0048 had unsealed penetrations into the Chapel.
2. Basement pipe chase 0053 had an unsealed penetration in the corridor.

Interview with the Facility Maintenance Manager on February 28, 2012 at 3:40 pm confirmed the unsealed pipe chase penetrations listed above.


18006

K 020

Based upon observation and interview, it was determined that the vertical openings between floors are not enclosed with construction having a fire resistive rating of 1 hour on two of four building levels.

Findings include:

Observation on February 28, 2012 between 3:00 p.m. and 3:35 p.m. revealed the following vertical openings were deficient:
A. Facility removed first floor corridor water fountain, and this location is also part of a pipe chase shaft. Facility patched this large area with thin metal. Facility must verify the corrective action has not negated the 2-hour fire rating of the shaft (3:00 p.m.)
B. Ladder, broom, shovel, and shop vacuum is stored in the basement pipe chase shaft 0017 (3:35 p.m.)

Interview with Fire Marshal on February 28, 2012 at 3:35 p.m. confirmed the 2-hour fire rated shafts do not comply with regulations.

K 027

Based upon observation and interview, the smoke barrier door assemblies do not comply with regulations on one of three floors

Findings include:

Observation on February 28, 2012 at 9:35 am revealed the second floor smoke barrier door 0205 that was equipped with latching hardware did not close completely and latch with the self-closer.

Interview with the Fire Marshal on February 28, 2012 at 9:35 am confirmed the smoke barrier door did dot close completely or latch.

K 029

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in compliance with regulations on one of three floors.

Findings include:

Observation on February 28, 2012 at 11:10 am revealed that the basement soiled utility room corridor door lacked positive latching with the self-closer.

Interview with the Fire Marshal on February 28, 2012 at 11:10 am confirmed the soiled utility room lacked positive latching with the self-closer.

K 033

Based upon observation and interview, the exit egress components do not have a fire resistive rating of at least one hour or are not arranged to provide a continuous path of egress as per regulations on one of four floors.

Findings include:

Observation on February 29, 2012 at 10:30 am revealed that the first floor stairwell 0114 lacked positive latching with the self-closer.

Interview with the Facility Maintenance Manager on February 29, 2012 at 10:30 am confirmed the stairwell door lacked positive latching with the self-closer.

K 038

Based upon observation and interview, it was determined that a readily accessible exit was not maintained according to regulations on two of four building levels.

Findings include:

Observation on February 28, 2012 between 9:50 a.m. and 11:17 a.m. revealed the following exits were not readily accessible:
A. Basement exit door in the back of dining would not open, except by excessive force (9:50 a.m.).
B. First floor patient room door 0181 sticks in the frame and is not easily opened, or closed (11:17 a.m.).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:17 a.m. confirmed the above exits are not easily accessible.

K 047

Based upon observation and interview, emergency lighting is not in accordance with regulations on two of four building levels.

Findings include:

1. Observation on February 28, 2012 between 1:00 pm and 1:15 pm revealed the following exit signs lack illumination:
A. Third floor, both exits (1:00 pm).
B. Second floor stair tower to third floor near 0245 group area (1:15 pm).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 1:15 pm confirmed the above exit signs are not illuminated.

2. Observation on February 29, 2012 at 10:00 am 10:05 am revealed the following exit signs lack illumination:
A. First floor above stairwell door 0129
B. First floor at door 0122.

Interview with the Facility Maintenance Manager on February 29, 2012 at 10:05 am confirmed the above listed exit signs were not illuminated.

K 050

Based upon review of documentation and interview, it was determined that the facility failed to perform fire drills as directed by regulations on three of four annual quarters.

Findings include:

Document review on February 29, 2012 at 11:15 am revealed facility lacks documentation that fire drills were conducted during the first shift of first, second, and fourth quarters 2011.

Interview with the Fire Marshal on February 29, 2012 at 11:15 am confirmed the lack of fire drill documentation.

K 051

Based on observation, document review and interview, the fire alarm systems with approved components, devices or equipment is installed and maintained in accordance with regulations in all areas of the building.

Findings include:

A. Document review on February 29, 2012 at 10:00 am revealed Fire Marshal performs testing of the entire fire alarm system. In accordance with NFPA 72, testing shall be performed by qualified and experienced personnel in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with qualifications as listed in NFPA 72, 7.1.2.2.

Interview with Fire Marshal on February 29, 2012 at 10:00 am confirmed the fire alarm shall be tested in accordance with NFPA 72.

B. Observation on February 28, 2012 revealed the basement fire alarm pull station by the smoke barrier was blocked from view by the smoke doors that held in the open position with the fire alarm system magnetic door hold-open.

Interview with the Fire Marshal on February 28, 2012 confirmed that the fire alarm pull station was blocked from view by the open smoke barrier door.

C. Document review on February 29, 2012 at 10:15 am revealed last fire alarm print-out from June 2, 2011 indicated continuous system trouble during testing, lost communication with MXM #19 (up to 5 seconds at a time). Facility shall verify alarm signals will activate the fire alarm system at any and all times.

Interview with Fire Marshal on February 29, 2012 at 10:15 am confirmed communication is lost within the fire alarm system.

K 054

Based upon observation, documentation review and interview, it was determined the required smoke detectors are not maintained, inspected and/or tested in accordance with regulation on one of three floors.

Findings include:

Observation on February 28, 2012 at 2:55 p.m. revealed that the 0218 laundry room smoke detector was cover rendering it inoperable.

Interview with the Facility Maintenance Manager on February 28, 2012 at 2:55 p.m. confirmed the smoke detector was covered.

K 061

Based upon observation and interview, it was determined that the required automatic sprinkler system lacks supervised valves, so that a local alarm will sound when closed in accordance with regulations for one of one fire sprinkler system.

Findings include:

Observation on February 28, 2012 at 11:50 a.m. revealed the outside post indicator valve lacks a supervisory electrical tamper switch.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:50 a.m. confirmed the lack of tamper switch on the post indicator valve.

K 062

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

Findings include:

Observation on February 28, 2012 at 3:30 p.m. revealed laundry room fire sprinkler heads indicate potential damage due to contact with laundry bags (plastic was hanging from sprinkler heads). Facility shall install fire sprinkler guards to protect the heads in this location.

Interview with Fire Marshal on February 28, 2012 at 3:30 p.m. confirmed the fire sprinkler heads shall be protected.

K 063

Based upon observation and interview, the fire sprinkler pump location is not in accordance with regulations for one of one fire pump.

Findings include:

Observation on February 28, 2012 at 9:20 a.m. revealed basement fire pump room door 54 lacks positive latching with self closure.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 9:20 a.m. confirmed fire pump room door lacks positive latching.

K 076

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on one of five building levels.

Findings include:

Observation on February 27, 2012 at 1:45 pm revealed third floor treatment room 0334, Ward #4 has an oxygen cylinder (H-tank) that is colored black (shall be colored green). Medical gas cylinders within a health care facility shall comply with the Compressed Gas Association's guidelines for coloring.

Interview with Chief Operating Officer on February 27, 2012 at 1:45 pm confirmed the oxygen cylinder tank color was not in accordance with regulations.

K 130

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 on one of four building levels.

Findings include:

1. Interview and review of documents revealed the Beistel building had construction work occur and occupied the area without an occupancy permit given from Department of Health, Drawing # H-08-0853

Interview with Facility Maintenance Manager 1 confirmed the facility failed to seek and occupancy inspection from the Department of Health.

2. Interview and review of documents revealed the Beistel building had construction work occur and occupied the area without an occupancy permit given from Department of Health, Drawing # H-10-0034.

Interview with Facility Maintenance Manager 1 confirmed the facility failed to seek and occupancy inspection from the Department of Health.

K 144

Based upon documentation review and interview it was determined that the facility failed to comply with regulations for generators which would effect the entire building.

Findings include:

Observation on February 27, 2012 at 3:45 pm revealed that the facility lacks a remote annunciator with both audible and visual alarm signals outside of the generator area in a location readily observed by operation personal at a regular work station.

Interview with the Fire Marshal on February 27, 2012 at 3:45 pm confirmed that the facility lacks a remote annunciator for the the emergency generator.




18006

K 144

Based upon documentation review and interview, it was determined that the facility failed to comply with regulations for one of one generator.

Findings include:

1. Document review on February 29, 2012 at 11:00 am revealed facility performs annual preventative maintenance and testing in-house. Generators shall have an annual service/testing done by a third-party entity.

Interview with the Fire Marshal on February 29, 2012 at 11:00 am confirmed the generators shall be serviced/tested by a third-party outside agency.

2. Observation on February 28, 2012 at 11:30 am revealed that the facility lacks a remote annunciator with both audible and visual alarm signals outside of the generator area in a location readily observed by operation personal at a regular work station.

Interview with the Fire Marshal on February 28, 2012 at 11:30 am confirmed that the facility lacks a remote annunciator for the the emergency generator

K 147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of two floors.

Findings include:

Observation on February 28, 2012 between 10:10 am and 10:45 am revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
1. First floor Observation Room 133A had a microwave oven plugged into a surge protector.
2. First floor Observation Room 0170 had microwave oven plugged into a surge protector.
3. Basement room 0025 had an air conditioner unit plugged into a surge protector.

Interview with the Fire Marshal on February 28, 2012 at 10:45 am confirmed that surge protectors were being utilized for unapproved applications.

K 211

Based upon observation and interview, alcohol based hand sanitizers (ABHS) are not installed or stored according to regulations on one of three floors.

Findings include:

Observation on February 27, 2012 at 1:05 pm revealed that the facility had a alcohol based hand sanitizer (ABHS) in stalled directly above a light switch in room 0353.

Interview with the Fire Marshal on February 27, 2012 at 1:05 p.m. confirmed that alcohol based hand sanitizer was installed above a light switch.