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 012

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

Findings include:

Observation on February 27, 2012 between 1:35 pm and 2:45 pm revealed the following floor/ceiling assemblies are not adequately sealed:
A. Third floor pipe chase 0505 has floor level unsealed water pipe (1:35 pm).
B. Second floor pipe chase 0242 has floor level exhaust vents that are not properly capped off (2:45 pm).

Interview with Chief Operating Officer on February 27, 2012 at 2:45 pm confirmed the unsealed floor penetrations.

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 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 per regulation on two of three floors within the facility.

Findings include:

1. Observation on February 28, 2012 between 9:30 am and 10:40 am revealed the facility had pipe chase shafts that are used for air exhaust purposes that only have fire dampers to protect the openings into bath and shower rooms. This condition occurs at the following locations:
A. The entire first floor pipe chase shaft closets.
B. The entire second floor pipe chase shaft closets.

Interview with the Fire Marshal on February 28, 2012 at 10:40 am confirmed that the pipe chase shafts are only protected with fire dampers.

2. Observation on February 28, 2012 at 10:15 am revealed the first floor pipe chase shaft 139 had unsealed penetrations above the corridor on the shaft side.

Interview with the Fire Marshal on February 28, 2012 at 10:15 am confirmed the unsealed penetration in the shaft wall.

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 five building levels.

Findings include:

Observation on February 27, 2012 between 3:00 pm and 3:20 pm revealed the following vertical openings were deficient:
A. First floor stair tower #4 double doors lack positive latching (3:00 pm).
B. First floor main lobby stair tower 0100 doors (both sets) lack positive latching (3:20 pm).

Interview with Chief Operating Offier on February 27, 2012 at 3:20 pm confirmed the 2-hour fire rated shafts do not comply with regulations.

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 four building levels.

Findings include:

Observation on February 28, 2012 at 2:00 p.m. revealed first floor stair tower door 0113 lacks positive latching.

Interview with Fire Marshal on February 28, 2012 at 2:00 p.m. confirmed the 2-hour fire rated shaft does not comply with regulations.

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 11:13 a.m. and 11:25 a.m. revealed the following vertical openings were deficient:
A. Second floor shaft door 269 lacks positive latching with self closure (11:13 a.m.).
B. First floor shaft 0178 has a conduit that needs plugged (11:17 a.m.).
C. First floor exit stair tower, near 161, has a shower stall stored within the stair tower (11:25 a.m.).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:25 a.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 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 27, 2012 at 2:50 pm revealed an unsealed penetration of the smoke barrier above the perforated ceiling at the 0201 smoke barrier doors.

Interview with the Fire Marshal on February 27, 2012 at 2:50 pm confirmed the unsealed penetration of the smoke barrier.

K 027

Based on observation and interview, door openings in smoke barriers have at least a 20 minute fire protection rating, or are at least 1-3/4 inch solid bonded core wood on one of four building levels.

Findings include:

Observation on February 28, 2012 at 11:05 a.m. revealed second floor smoke barrier doors near room 243 have a gap greater than 1/8" when in the closed position (doors do not close completely in the frame).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:05 a.m. confirmed the smoke barrier doors do not close completely in the frame.

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 029

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

Findings include:

Observation on February 28, 2012 at 2:10 pm revealed first floor shower room/storage 0117 door lacks positive latching.

Interview with Fire Marshal on February 28, 2012 at 2:10 pm confirmed the storage room door does not latch with a self-closure.

K 029

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

Findings include:

Observation on February 28, 2012 at 3:40 p.m. revealed basement storage room 0019 door lacks correctly installed self-closure (arm removed).

Interview with Fire Marshal on February 28, 2012 at 3:40 p.m. confirmed the storage room door does not latch with a self-closure.

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 047

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

Findings include:

Observation on February 28, 2012 between 1:45 pm and 2:15 pm revealed the following exit signs lack illumination:
A. Third floor both exit signs (1:45 pm).
B. Basement room 0008 both exit signs (2:15 pm).

Interview with Fire Marshal on February 28, 2012 at 2:15 pm confirmed the above exit signs are not illuminated.

K 047

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

Findings include:

Observation on February 28, 2012 between 2:45 p.m. and 3:10 p.m. revealed the following exit signs lack illumination:
A. First floor exit door on Ward #1 to front of building (2:45 p.m.).
B. Basement above stair tower door 0197 (3:10 p.m.).

Interview with Fire Marshal on February 28, 2012 at 3:10 p.m. confirmed the above exit signs are 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 051

Based on document review and interview, the fire alarm system 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. Document review on February 29, 2012 at 10:15 am revealed last building fire alarm test print-out indicates building has a continuous trouble signal on the fire alarm system, but facility can not indicate where the trouble is located.

Interview with Fire Marshal on February 29, 2012 at 10:15 am confirmed the fire alarm has trouble signal that is not located on the system.

K 051

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

Findings include:

Document review on February 29, 2012 at 10:00 a.m. 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 a.m. confirmed the fire alarm shall be tested in accordance with NFPA 72.

K 051

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

Findings include:

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.

K 051

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

Findings include:

A. Observation on February 27, 2012 at 2:30 pm revealed computer monitor in guard office shows auto-dialer is turned off. No audible trouble signal was alarming at this location. Interview with Security noted the facility manually turns off the fire alarm auto-dialer while "hot-work" is underway.

If facility chooses to continue this practice, facility shall verify means for silencing the audible call-in signal is key-operated, in a locked cabinet, or provided with protection to prevent use by unauthorized persons. The means shall operate a visible indicator and sound a trouble signal whenever the means is in the silence position and there are no telephone circuits in an off-hook condition.

Interview with Chief Operating Officer on February 27, 2012 at 2:30 pm confirmed the auto-dialer was turned off and no audible alarm was sounding.

B. 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.

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 062

Based upon observation and interview, the facility did not inspect, test and/or maintain the required automatic sprinkler system as per regulations, NFPA 9.7.5, 18.7.6, 19.7.6, NFPA 13, NFPA 25 on one of four building levels.

Findings include:

Observation on February 28, 2012 at 9:25 a.m. revealed basement room 0054 has ceiling tile removed. This may delay the function of the fire sprinkler head if needed.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 9:25 a.m. confirmed the ceiling tile was removed.

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 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. Observation on February 28, 2012 at 11:15 am revealed Wiseman #3, second floor is currently undergoing renovations. Due to the renovations, facility has exposed wiring, removed electrical outlet covers, and sprinkler heads are capped. Facility shall maintain safety measures in this location during construction.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:15 am confirmed the facility shall have safety measures in place during the time of construction.

2. Interview and review of documents revealed the Wiseman building was occupied without an occupancy permit given from Department of Health, Drawing # H-08-0427.

Interview with the Facility Manager 1 confirmed the facilty did not seek to obtain an occupancy from the Department of Health.

3. Interview and review of documents revealed the Wiseman building had construction work occur without an occupancy permit given from Department of Health, Drawing # H-10-0829

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 144

Based upon observation, 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:

1. 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

2. 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.

K 144

Based on document review, observation and interview, generators are inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with regulations for one of one emergency generator.

Findings include:

A. Observation on February 28, 2012 at 10:20 a.m. revealed the emergency generator remote annunciator panel lacks an audible sound when the test button is depressed. Facility shall verify the annunciator panel will sound an alarm if there are faults with the emergency generator.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 10:20 a.m. confirmed the audible sound on the remote annunciator panel did not activate when tested.

B. Document review on February 29, 2012 at 11:00 a.m. 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 a.m. confirmed the generators shall be serviced/tested by a third-party outside agency.

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 a.m. 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 a.m. confirmed the generators shall be serviced/tested by a third-party outside agency.

A. Observation on February 28, 2012 at 11:30 a.m. 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 a.m. confirmed that the facility lacks a remote annunciator for the the emergency generator.

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 144

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

Findings include:

A. Observation on February 28, 2012 at 2:20 pm revealed facility lacks battery-pack emergency lighting at the basement emergency generator location.

Interview with Fire Marshal on February 28, 2012 at 2:20 pm confirmed the inside emergency generator location lacks battery pack lighting.

B. 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.

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 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 four of four building levels.

Findings include:

1. Observation on February 28, 2012 between 2:35 p.m. and 3:20 p.m. revealed the following electrical concerns:
A. Third floor penthouse elevator equipment room 0301 has an air conditioner plugged into an extension cord (2:35 p.m.).
B. Second floor office 0294 has a surge protector plugged into another surge protector (2:40 p.m.).
C. First floor pipe chase 0183 has an air conditioner plugged into an extension cord (3:05 p.m.).
D. Basement office 0032 has a microwave oven plugged into a surge protector (3:20 p.m.).

Interview with Fire Marshal on February 28, 2012 at 3:20 p.m. confirmed the above electrical issues.

2. Observation on February 28, 2012 between 2:40 p.m. and 2:50 p.m. revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
A. Second floor room 0200 had a microwave oven and a refrigerator plugged into a surge protector.
B. Second floor room 210 had a surge protector plugged into another surge protector.
C. Second floor room 0251 had a microwave oven and a refrigerator plugged into a surge protector.

Interview with the Facility Maintenance Manager on February 28, 2012 at 2:50 p.m. confirmed that surge protectors were being utilized for unapproved applications.

3. Observation on February 28, 2012 at 3:45 p.m. revealed that basement room 0022 had an air conditioner plugged into an extension cord.

Interview with the Facility Maintenance Manager on February 28, 2012 at 3:45 p.m. confirmed the unapproved utilization of an extension cord in room 0022.

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 four of four building levels.

Findings include:

Observation on February 28, 2012 between 9:20 am and 11:20 am revealed the following electrical concerns:
A. Basement fire pump room 54 has a missing electrical cover plate (9:20 am).
B. Basement chase/shaft 0036 has an extension cord (9:45 am).
C. Basement kitchen maintenance room closet has exposed wiring in a corrugated conduit (9:55 am).
D. Basement office 0013B has an air conditioner plugged into an extension cord, and extension cord is plugged into a surge protector (9:57 am).
E. Basement room 12 has an open junction box at ceiling (10:00 a.m.).
F. First floor control room has a refrigerator and microwave oven plugged into an extension cord, and extension cord is plugged into a surge protector (10:17 a.m.).
G. First floor room 151 has an air conditioner cord spliced and altered (10:25 a.m.).
H. First floor chase/shaft 122 has an extension cord (10:30 a.m.).
I. Second floor sun porch has a surge protector plugged into another surge protector (10:35 a.m.).
J. Second floor chase/shaft 213 has an extension cord (10:50 a.m.).
K. Second floor office 200F Suite has an extension cord (11:00 a.m.).
L. Second floor office 247 has an extension cord connecting two surge protectors (11:10 a.m.).
M. Second floor office 247 has an air conditioner cord spliced and altered (11:10 a.m.).
N. First floor chase/shaft 0178 has an extension cord (11:16 a.m.).
O. First floor chase/shaft 165 lacks a light switch cover plate (11:20 am).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:20 a.m. confirmed the above electrical issues.

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 four floor levels.

Findings include:

1. Observation on February 28, 2012 at 1:30 pm revealed second floor office cubicle closest to stair tower door 0140 has three surge protectors plugged into other surge protectors (daisy-chained).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 1:30 pm confirmed the surge protectors shall be plugged directly into an electrical receptacle.

2. Observation on February 28, 2012 between 1:10 pm and 1:40 pm revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
A. First floor room 112 had a surge plugged into ban extension cord.
B. First floor room 0139 had a surge protector plugged into another surge protector and a microwave oven plugged into a surge protector.
C. First floor room 0147 had a surge protector plugged into an extension cord.

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

3. Observation on February 29, 2012 at 10:15 am revealed a copy machine on the first floor near door 0124 was plugged into an extension cord.

Interview with the Facility Maintenance Manager on February 29, 2012 at 10:15 am confirmed that the facility was utilizing a extension cord for an unapproved application.

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 three of five building levels.

Findings include:

1. Observation on February 27, 2012 between 1:40 p.m. and 3:30 p.m. revealed the following electrical concerns:
A. Third floor pipe chase 0332 has an extension cord (1:40 p.m.).
B. Second floor office 0245 has a surge protector cord placed across door opening (2:00 p.m.).
C. Second floor doctor office 0262 has an extension cord plugged into a surge protector (2:20 p.m.).
D. First floor office 0192 has a surge protector plugged into another surge protector, and an extension cord plugged into a surge protector (2:47 p.m.).
E. First floor conference room 0195 has a microwave oven and coffee pot plugged into a surge protector (2:48 p.m.).
F. First floor human resources area 1202A has a surge protector plugged into a surge protector, and a microwave oven plugged into an extension cord (3:15 p.m.).
G. First floor guardian office 0104 has a microwave oven, coffee pot, and refrigerator plugged into a surge protector (3:30 p.m.).

Interview with Chief Operating Officer on February 27, 2012 at 3:30 p.m. confirmed the above electrical issues.

2. Observation on February 27, 2012 between 1:20 p.m. and 3:30 p.m. revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
A. Third floor nurses station 03412 had a surge protector plugged into another surge protector
B. Third floor room 0322 had a refrigerator, microwave oven, coffee pot and toaster plugged into a surge protector
C. Second floor room 2334 employee break room had a microwave oven plugged into a surge protector.
D. Second floor room 2313 had a coffee pot and microwave oven plugged into a surge protector.
E. Second floor room 0222 had a refrigerator and microwave plugged into a surge protector.
F. First floor room 1222 had a microwave oven plugged into a surge protector.
G First floor room 1205 had microwave oven and coffee pot plugged into a surge protector
H. First floor room 165 had a microwave oven plugged into an extension cord.

Interview with the Fire Marshal on February 27, 2012 at 3:30 p.m. confirmed the facility was utilizing surge protectors for unapproved applications at the above listed locations.

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 two of four building levels.

Findings include:

1. Observation on February 28, 2012 between 1:45 pm and 2:03 pm revealed the following electrical concerns:
A. Third floor room 0301 lacks an electrical switch cover plate (1:45 pm).
B. First floor HIPPA office 113 has a surge protector plugged into another surge protector, daisy-chained (2:03 pm).

Interview with Fire Marshal on February 28, 2012 at 2:03 pm confirmed the above electrical issues.

2. Observation on February 29, 2012 between 2:00 pm and 2:30 pm revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
A. First floor room 113 had an extension cord plugged into a surge protector
B. First floor room 113 had two toaster ovens and a microwave oven plugged into a surge protector.
C. First floor room 0107 had two microwave ovens plugged into a surge protector.

Interview with the Fire Marshal on February 28, 2012 at 2:30 am confirmed that the above listed 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.

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 012

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

Findings include:

Observation on February 27, 2012 between 1:35 pm and 2:45 pm revealed the following floor/ceiling assemblies are not adequately sealed:
A. Third floor pipe chase 0505 has floor level unsealed water pipe (1:35 pm).
B. Second floor pipe chase 0242 has floor level exhaust vents that are not properly capped off (2:45 pm).

Interview with Chief Operating Officer on February 27, 2012 at 2:45 pm confirmed the unsealed floor penetrations.

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 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 per regulation on two of three floors within the facility.

Findings include:

1. Observation on February 28, 2012 between 9:30 am and 10:40 am revealed the facility had pipe chase shafts that are used for air exhaust purposes that only have fire dampers to protect the openings into bath and shower rooms. This condition occurs at the following locations:
A. The entire first floor pipe chase shaft closets.
B. The entire second floor pipe chase shaft closets.

Interview with the Fire Marshal on February 28, 2012 at 10:40 am confirmed that the pipe chase shafts are only protected with fire dampers.

2. Observation on February 28, 2012 at 10:15 am revealed the first floor pipe chase shaft 139 had unsealed penetrations above the corridor on the shaft side.

Interview with the Fire Marshal on February 28, 2012 at 10:15 am confirmed the unsealed penetration in the shaft wall.

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 five building levels.

Findings include:

Observation on February 27, 2012 between 3:00 pm and 3:20 pm revealed the following vertical openings were deficient:
A. First floor stair tower #4 double doors lack positive latching (3:00 pm).
B. First floor main lobby stair tower 0100 doors (both sets) lack positive latching (3:20 pm).

Interview with Chief Operating Offier on February 27, 2012 at 3:20 pm confirmed the 2-hour fire rated shafts do not comply with regulations.

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 four building levels.

Findings include:

Observation on February 28, 2012 at 2:00 p.m. revealed first floor stair tower door 0113 lacks positive latching.

Interview with Fire Marshal on February 28, 2012 at 2:00 p.m. confirmed the 2-hour fire rated shaft does not comply with regulations.

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 11:13 a.m. and 11:25 a.m. revealed the following vertical openings were deficient:
A. Second floor shaft door 269 lacks positive latching with self closure (11:13 a.m.).
B. First floor shaft 0178 has a conduit that needs plugged (11:17 a.m.).
C. First floor exit stair tower, near 161, has a shower stall stored within the stair tower (11:25 a.m.).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:25 a.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 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 27, 2012 at 2:50 pm revealed an unsealed penetration of the smoke barrier above the perforated ceiling at the 0201 smoke barrier doors.

Interview with the Fire Marshal on February 27, 2012 at 2:50 pm confirmed the unsealed penetration of the smoke barrier.

K 027

Based on observation and interview, door openings in smoke barriers have at least a 20 minute fire protection rating, or are at least 1-3/4 inch solid bonded core wood on one of four building levels.

Findings include:

Observation on February 28, 2012 at 11:05 a.m. revealed second floor smoke barrier doors near room 243 have a gap greater than 1/8" when in the closed position (doors do not close completely in the frame).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:05 a.m. confirmed the smoke barrier doors do not close completely in the frame.

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 029

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

Findings include:

Observation on February 28, 2012 at 2:10 pm revealed first floor shower room/storage 0117 door lacks positive latching.

Interview with Fire Marshal on February 28, 2012 at 2:10 pm confirmed the storage room door does not latch with a self-closure.

K 029

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

Findings include:

Observation on February 28, 2012 at 3:40 p.m. revealed basement storage room 0019 door lacks correctly installed self-closure (arm removed).

Interview with Fire Marshal on February 28, 2012 at 3:40 p.m. confirmed the storage room door does not latch with a self-closure.

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 047

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

Findings include:

Observation on February 28, 2012 between 1:45 pm and 2:15 pm revealed the following exit signs lack illumination:
A. Third floor both exit signs (1:45 pm).
B. Basement room 0008 both exit signs (2:15 pm).

Interview with Fire Marshal on February 28, 2012 at 2:15 pm confirmed the above exit signs are not illuminated.

K 047

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

Findings include:

Observation on February 28, 2012 between 2:45 p.m. and 3:10 p.m. revealed the following exit signs lack illumination:
A. First floor exit door on Ward #1 to front of building (2:45 p.m.).
B. Basement above stair tower door 0197 (3:10 p.m.).

Interview with Fire Marshal on February 28, 2012 at 3:10 p.m. confirmed the above exit signs are 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 051

Based on document review and interview, the fire alarm system 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. Document review on February 29, 2012 at 10:15 am revealed last building fire alarm test print-out indicates building has a continuous trouble signal on the fire alarm system, but facility can not indicate where the trouble is located.

Interview with Fire Marshal on February 29, 2012 at 10:15 am confirmed the fire alarm has trouble signal that is not located on the system.

K 051

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

Findings include:

Document review on February 29, 2012 at 10:00 a.m. 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 a.m. confirmed the fire alarm shall be tested in accordance with NFPA 72.

K 051

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

Findings include:

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.

K 051

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

Findings include:

A. Observation on February 27, 2012 at 2:30 pm revealed computer monitor in guard office shows auto-dialer is turned off. No audible trouble signal was alarming at this location. Interview with Security noted the facility manually turns off the fire alarm auto-dialer while "hot-work" is underway.

If facility chooses to continue this practice, facility shall verify means for silencing the audible call-in signal is key-operated, in a locked cabinet, or provided with protection to prevent use by unauthorized persons. The means shall operate a visible indicator and sound a trouble signal whenever the means is in the silence position and there are no telephone circuits in an off-hook condition.

Interview with Chief Operating Officer on February 27, 2012 at 2:30 pm confirmed the auto-dialer was turned off and no audible alarm was sounding.

B. 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.

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 062

Based upon observation and interview, the facility did not inspect, test and/or maintain the required automatic sprinkler system as per regulations, NFPA 9.7.5, 18.7.6, 19.7.6, NFPA 13, NFPA 25 on one of four building levels.

Findings include:

Observation on February 28, 2012 at 9:25 a.m. revealed basement room 0054 has ceiling tile removed. This may delay the function of the fire sprinkler head if needed.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 9:25 a.m. confirmed the ceiling tile was removed.

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 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. Observation on February 28, 2012 at 11:15 am revealed Wiseman #3, second floor is currently undergoing renovations. Due to the renovations, facility has exposed wiring, removed electrical outlet covers, and sprinkler heads are capped. Facility shall maintain safety measures in this location during construction.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:15 am confirmed the facility shall have safety measures in place during the time of construction.

2. Interview and review of documents revealed the Wiseman building was occupied without an occupancy permit given from Department of Health, Drawing # H-08-0427.

Interview with the Facility Manager 1 confirmed the facilty did not seek to obtain an occupancy from the Department of Health.

3. Interview and review of documents revealed the Wiseman building had construction work occur without an occupancy permit given from Department of Health, Drawing # H-10-0829

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 144

Based upon observation, 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:

1. 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

2. 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.

K 144

Based on document review, observation and interview, generators are inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with regulations for one of one emergency generator.

Findings include:

A. Observation on February 28, 2012 at 10:20 a.m. revealed the emergency generator remote annunciator panel lacks an audible sound when the test button is depressed. Facility shall verify the annunciator panel will sound an alarm if there are faults with the emergency generator.

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 10:20 a.m. confirmed the audible sound on the remote annunciator panel did not activate when tested.

B. Document review on February 29, 2012 at 11:00 a.m. 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 a.m. confirmed the generators shall be serviced/tested by a third-party outside agency.

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 a.m. 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 a.m. confirmed the generators shall be serviced/tested by a third-party outside agency.

A. Observation on February 28, 2012 at 11:30 a.m. 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 a.m. confirmed that the facility lacks a remote annunciator for the the emergency generator.

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 144

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

Findings include:

A. Observation on February 28, 2012 at 2:20 pm revealed facility lacks battery-pack emergency lighting at the basement emergency generator location.

Interview with Fire Marshal on February 28, 2012 at 2:20 pm confirmed the inside emergency generator location lacks battery pack lighting.

B. 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.

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 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 four of four building levels.

Findings include:

1. Observation on February 28, 2012 between 2:35 p.m. and 3:20 p.m. revealed the following electrical concerns:
A. Third floor penthouse elevator equipment room 0301 has an air conditioner plugged into an extension cord (2:35 p.m.).
B. Second floor office 0294 has a surge protector plugged into another surge protector (2:40 p.m.).
C. First floor pipe chase 0183 has an air conditioner plugged into an extension cord (3:05 p.m.).
D. Basement office 0032 has a microwave oven plugged into a surge protector (3:20 p.m.).

Interview with Fire Marshal on February 28, 2012 at 3:20 p.m. confirmed the above electrical issues.

2. Observation on February 28, 2012 between 2:40 p.m. and 2:50 p.m. revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
A. Second floor room 0200 had a microwave oven and a refrigerator plugged into a surge protector.
B. Second floor room 210 had a surge protector plugged into another surge protector.
C. Second floor room 0251 had a microwave oven and a refrigerator plugged into a surge protector.

Interview with the Facility Maintenance Manager on February 28, 2012 at 2:50 p.m. confirmed that surge protectors were being utilized for unapproved applications.

3. Observation on February 28, 2012 at 3:45 p.m. revealed that basement room 0022 had an air conditioner plugged into an extension cord.

Interview with the Facility Maintenance Manager on February 28, 2012 at 3:45 p.m. confirmed the unapproved utilization of an extension cord in room 0022.

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 four of four building levels.

Findings include:

Observation on February 28, 2012 between 9:20 am and 11:20 am revealed the following electrical concerns:
A. Basement fire pump room 54 has a missing electrical cover plate (9:20 am).
B. Basement chase/shaft 0036 has an extension cord (9:45 am).
C. Basement kitchen maintenance room closet has exposed wiring in a corrugated conduit (9:55 am).
D. Basement office 0013B has an air conditioner plugged into an extension cord, and extension cord is plugged into a surge protector (9:57 am).
E. Basement room 12 has an open junction box at ceiling (10:00 a.m.).
F. First floor control room has a refrigerator and microwave oven plugged into an extension cord, and extension cord is plugged into a surge protector (10:17 a.m.).
G. First floor room 151 has an air conditioner cord spliced and altered (10:25 a.m.).
H. First floor chase/shaft 122 has an extension cord (10:30 a.m.).
I. Second floor sun porch has a surge protector plugged into another surge protector (10:35 a.m.).
J. Second floor chase/shaft 213 has an extension cord (10:50 a.m.).
K. Second floor office 200F Suite has an extension cord (11:00 a.m.).
L. Second floor office 247 has an extension cord connecting two surge protectors (11:10 a.m.).
M. Second floor office 247 has an air conditioner cord spliced and altered (11:10 a.m.).
N. First floor chase/shaft 0178 has an extension cord (11:16 a.m.).
O. First floor chase/shaft 165 lacks a light switch cover plate (11:20 am).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 11:20 a.m. confirmed the above electrical issues.

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 four floor levels.

Findings include:

1. Observation on February 28, 2012 at 1:30 pm revealed second floor office cubicle closest to stair tower door 0140 has three surge protectors plugged into other surge protectors (daisy-chained).

Interview with Facility Maintenance Manager 1 on February 28, 2012 at 1:30 pm confirmed the surge protectors shall be plugged directly into an electrical receptacle.

2. Observation on February 28, 2012 between 1:10 pm and 1:40 pm revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
A. First floor room 112 had a surge plugged into ban extension cord.
B. First floor room 0139 had a surge protector plugged into another surge protector and a microwave oven plugged into a surge protector.
C. First floor room 0147 had a surge protector plugged into an extension cord.

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

3. Observation on February 29, 2012 at 10:15 am revealed a copy machine on the first floor near door 0124 was plugged into an extension cord.

Interview with the Facility Maintenance Manager on February 29, 2012 at 10:15 am confirmed that the facility was utilizing a extension cord for an unapproved application.

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 three of five building levels.

Findings include:

1. Observation on February 27, 2012 between 1:40 p.m. and 3:30 p.m. revealed the following electrical concerns:
A. Third floor pipe chase 0332 has an extension cord (1:40 p.m.).
B. Second floor office 0245 has a surge protector cord placed across door opening (2:00 p.m.).
C. Second floor doctor office 0262 has an extension cord plugged into a surge protector (2:20 p.m.).
D. First floor office 0192 has a surge protector plugged into another surge protector, and an extension cord plugged into a surge protector (2:47 p.m.).
E. First floor conference room 0195 has a microwave oven and coffee pot plugged into a surge protector (2:48 p.m.).
F. First floor human resources area 1202A has a surge protector plugged into a surge protector, and a microwave oven plugged into an extension cord (3:15 p.m.).
G. First floor guardian office 0104 has a microwave oven, coffee pot, and refrigerator plugged into a surge protector (3:30 p.m.).

Interview with Chief Operating Officer on February 27, 2012 at 3:30 p.m. confirmed the above electrical issues.

2. Observation on February 27, 2012 between 1:20 p.m. and 3:30 p.m. revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
A. Third floor nurses station 03412 had a surge protector plugged into another surge protector
B. Third floor room 0322 had a refrigerator, microwave oven, coffee pot and toaster plugged into a surge protector
C. Second floor room 2334 employee break room had a microwave oven plugged into a surge protector.
D. Second floor room 2313 had a coffee pot and microwave oven plugged into a surge protector.
E. Second floor room 0222 had a refrigerator and microwave plugged into a surge protector.
F. First floor room 1222 had a microwave oven plugged into a surge protector.
G First floor room 1205 had microwave oven and coffee pot plugged into a surge protector
H. First floor room 165 had a microwave oven plugged into an extension cord.

Interview with the Fire Marshal on February 27, 2012 at 3:30 p.m. confirmed the facility was utilizing surge protectors for unapproved applications at the above listed locations.

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 two of four building levels.

Findings include:

1. Observation on February 28, 2012 between 1:45 pm and 2:03 pm revealed the following electrical concerns:
A. Third floor room 0301 lacks an electrical switch cover plate (1:45 pm).
B. First floor HIPPA office 113 has a surge protector plugged into another surge protector, daisy-chained (2:03 pm).

Interview with Fire Marshal on February 28, 2012 at 2:03 pm confirmed the above electrical issues.

2. Observation on February 29, 2012 between 2:00 pm and 2:30 pm revealed that the facility was utilizing surge protectors for unapproved applications at the following locations:
A. First floor room 113 had an extension cord plugged into a surge protector
B. First floor room 113 had two toaster ovens and a microwave oven plugged into a surge protector.
C. First floor room 0107 had two microwave ovens plugged into a surge protector.

Interview with the Fire Marshal on February 28, 2012 at 2:30 am confirmed that the above listed surge protectors were being utilized for unapproved applications.