The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| DANVILLE STATE HOSPITAL | 50 KIRKBRIDE DRIVE DANVILLE, PA 17821 | May 10, 2021 |
| VIOLATION: Corridor - Doors | Tag No: K0363 | |
| Based on observation and interview, it was determined the facility failed to maintain corridor doors on one of four floors. Findings include: 1. Observation on May 10, 2021, between 11:34 am and 11:42 am, revealed the following corridor doors were not smoke tight when latched in the frame. a. At 11:34 am, Unit 212, med-room dutch door. 2nd floor. b. At 11:42 am, Unit 213, med room door. 2nd floor. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the doors were not smoke tight. |
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| VIOLATION: Multiple Occupancies | Tag No: K0131 | |
| Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of four floors. Findings include: 1. Observation on May, 10, 2021, at 9:55 a.m., revealed a penetration of the common wall, at the tunnel level, at the Montour Building entrance. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the common wall deficiency. |
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| VIOLATION: Building Construction Type and Height | Tag No: K0161 | |
| Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors in this component. Findings include: 1. Observation on May 10, 2021, between 8:30 am and 1:30 pm, revealed the facility exceeds the maximum allowable story height for this type of construction. 2. Observation on May 10, 2021, between 9:44 a.m. and 9:52 a.m., revealed the following: a. 9:44 a.m., structural steel, located closest to Room 004, within the tunnel, lacked plaster. b. 9:52 a.m., structural steel, located within the tunnel-level, Room 0006, lacked intumescent spray, fire proofing paint in one location. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the facility exceeds the maximum allowable story height for this type of construction and the building construction deficiencies. |
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| VIOLATION: Exit Signage | Tag No: K0293 | |
| Based on observation and interview, it was determined the facility failed to maintain exit signage in five locations, affecting three of four floors. Findings include: 1. Observation on May, 10, 2021, between 9:33 a.m. and 1:04 p.m., revealed the following areas lacked illuminated exit signage: a. 9:33 a.m., tunnel, closest to the water heater. b. 10:12 a.m., tunnel, closest to the fourth riser. c. 11:33 a.m., within the 314 Unit, closest to stair tower 2055. d. 11:36 a.m., within the 314 Unit, closest to the Nurse's Station. e. 1:04 p.m., at the 313 Nurse's Station area. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the exit signage deficiencies. |
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| VIOLATION: Sprinkler System - Maintenance and Testing | Tag No: K0353 | |
| Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of four floors. Findings include: 1. Observation on May, 10, 2021, at 11:55 a.m., revealed a ceiling tile was lacking within the first floor Sunporch. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the automatic sprinkler system deficiency. |
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| VIOLATION: Subdivision of Building Spaces - Smoke Barrie | Tag No: K0374 | |
| Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier separation doors, affecting one of four floors. Findings include: 1. Observation on May, 10, 2021, at 1:10 p.m., revealed the Unit 310 smoke barrier separation doors required adjustment to fully close. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the smoke barrier separation door deficiency. |
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| VIOLATION: General Requirements - Other | Tag No: K0100 | |
| 28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. 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 meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility. Findings include: 1. Observation on May 10, 2021, at 12:00 pm, revealed the facility lacked state-approved plans for the major renovation work started on Unit 214, on the 2nd floor. Interview at the time of the exit conference with facility administrator, facility representative #1 and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the facility did not have Department of Health, Plan Review approved plans for the work being conducted. |
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| VIOLATION: Building Construction Type and Height | Tag No: K0161 | |
| Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting four of four floors in this component. Findings include: 1. Observation on May 10, 2021, between 8:30 am and 1:30 pm, revealed the facility exceeds the maximum allowable story height for this type of construction. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the facility exceeds the maximum allowable story height for this type of construction. |
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| VIOLATION: Vertical Openings - Enclosure | Tag No: K0311 | |
| Based on observation and interview, it was determined the facility failed to maintain vertical openings on one of four floors. Findings include: 1. Observation on May 10, 2021 at 11:51 am, revealed stairtower door 2224 failed to latch in the frame. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the door lacked positive latching. |
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| VIOLATION: Smoke Detection | Tag No: K0347 | |
| Based on observation and interview, it was determined the facility failed to maintain smoke detection units in one location, affecting one of four floors. Findings include: 1. Observation on May, 10, 2021, at 1:23 p.m., revealed the smoke detection unit, located within the first floor, 211 Alcove, was missing. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 p.m., confirmed the smoke detection unit deficiency. |
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| VIOLATION: Corridors - Construction of Walls | Tag No: K0362 | |
| Based on observation and interview, it was determined the faciity failed to maintain the fire resistance rating of corridor walls on two of four floors. Findings include: 1. Observation May 10, 2021, between 11:17 am, and 1:04 pm, revealed the following: a. At 11:17 am, in room 3110 an open penetration around an MC cable on the corridor wall, below the ceiling, 3rd floor. b. At 1:04 pm, an open 4 inch conduit was installed in the corridor wall in the clean linen room of Unit 213, 2nd floor. Interview at the time of the exit conference with facility administrator, facility representative #1, and maintenance representative #1 on May 10, 2021, at 2:00 pm, confirmed the corridor wall penetrations were not sealed. |
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