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GOOD SHEPHERD SPECIALTY HOSPITAL
Roles Under a Waiver Declared by Secretary
Tag No.: E0026
Based on documention review and interview, it was determined the facility failed to provide for the role of the facility under a waiver declared by the Secretary of the Department of Health.
Findings include:
1. Observation on March 15, 2019, at 11:11 a.m. revealed the facility lacked 1135 Waiver information within the Emergency Preparedness plan.
Exit interview with the Facility Administrator and Network Fire Marshall between 11:20 a.m. and 11:30 a.m. on March 15, 2019, confirmed the 1135 Waiver deficiency.
Multiple Occupancies - Construction Type
Tag No.: K0133
Based on observation and interview, it was determiend the facility failed to construct and maintain one common wall, affecting one of six total floors.
Findings include:
1. Observation on March 15, 2019, at 10:20 a.m. revealed the fifth floor lacked a common wall between the South Wing Building and the 1961 Building.
Exit interview with the Facility Administrator and Network Fire Marshall between 11:20 a.m. and 11:30 a.m. on March 15, 2019, confirmed the fifth floor common wall deficiency.
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 six total floors.
Findings include:
1. Observation on March 15, 2019, at 10:35 a.m. revealed wires partially blocked an upright sprinkler head assembly within the third floor Electrical Room.
Exit interview with the Facility Administrator and Network Fire Marshall between 11:20 a.m. and 11:30 a.m. on March 15, 2019, confirmed the sprinkler system deficiency.
Corridor - Doors
Tag No.: K0363
Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of six total floors.
Findings include:
1. Observation on March 15, 2019, at 10:33 a.m. revealed the third floor Staff Lounge door was held open by unapproved means (chair).
Exit interview with the Facility Administrator and Network Fire Marshall between 11:20 a.m. and 11:30 a.m. on March 15, 2019, confirmed the corridor opening deficiency.
Gas Equipment - Cylinder and Container Storag
Tag No.: K0923
Based on observation and interview, it was determiend the facility failed to maintain one medical gas storage location, affecting one of six total floors.
Findings include:
1. Observation on March 15, 2019, at 10:38 a.m. revealed 13 "e-style" oxygen cylinders located within the third floor clean utility room (250 cubic feet of oxygen is permissible per smoke compartment in this type of application).
Exit interview with the Facility Administrator and Network Fire Marshall between 11:20 a.m. and 11:30 a.m. on March 15, 2019, confirmed the oxygen storage deficiency.