HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain two-hour fire rated common walls in one instance, affecting one of three floors in this component.

Findings include:

1. Observation on August 5, 2013, at 10:53 AM revealed the common wall, located inside first floor electrical room A145, had an unsealed penetration at the floor level.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the unsealed penetration in the first floor common wall.

Based on observation and interview, it was determined the facility failed to maintain minimum construction requirements throughout six of six floors within this component.

Findings include:

1. Observation on August 08, 2013, between 09:45 a.m. and 11:15 a.m. revealed this building is an unprotected noncombustible, fully sprinklered structure. This type of building construction is not permitted to be greater than two stories in height.

Exit interview with the Facilities Manager and Security Manager between 11:15 a.m. and 11:30 a.m. on August 08, 2013, confirmed the construction type and height and identified that the facility has an acceptable FSES reviewed on August 08, 2013, addressing this issue.

Based on observation and interview, it was determined the facility failed to maintain corridor door openings in one location, on one of six floors.

Findings include:

1. Observation of the sixth floor Elevator Lobby at 10:33 a.m. on August 08, 2013, revealed the door lacked positive latching.

Exit interview with the Facilities Manager and Security Manager between 11:15 a.m. and 11:30 a.m. on August 08, 2013, confirmed the corridor door would not latch.

Based on observation and interview, it was determined the facility failed to maintain one exit passageway door, affecting three of three floors in this component.

Findings include:

1. Observation on August 5, 2013, at 10:48 AM revealed the first floor north exit stair tower door was held open by a wedge.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the stair tower door was held open by a wedge.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area, affecting one of three floors in this component.

Findings include:

1. Observation on August 5, 2013, at 11:40 AM revealed the basement electrical room 002 had unsealed penetrations in the fire rated wall above the door.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the unsealed penetrations in the electrical room.

Based on observation and interview, it was determined the facility failed to maintain exit stair towers in one instance, on one of three floors within the component.

Findings include:

1. Observation on August 5, 2013, at 10:55 AM revealed an unsealed penetration around the sprinkler pipe, above the door, at the 2nd floor (facility 1st floor) stairwell "E".

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the unsealed penetration.

Based on observation and interview, it was determined the facility failed to provide complete automatic sprinkler coverage to one area, affecting one of four levels in this component.

Findings include:

1. Observation on August 5, 2013, at 11:29AM revealed the basement telephone equipment room (005) lacked sprinkler coverage.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the telephone equipment room did not have sprinklers installed.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in one instance, on one of three floors within the component.

Findings include:

1. Observation on August 5, 2013, at 10:45 AM revealed communication wires were attached to the sprinkler piping, located in the 3rd floor (facility 2nd floor) corridor near rooms' 235-237.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the wires were supported by the sprinkler piping.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in two instances, on one of two floors within the component.

Findings include:

1. Observation on August 5, 2013, between 10:08 AM and 10:20 AM revealed the following fire extinguishers were missing inspections:

a. 10:08 AM - The fire extinguisher, located in the 1st floor (facility basement level) Medical Air Room, had an annual inspection tag dated 2010.
b. 10:20 AM - The fire extinguisher, located in the 1st floor (facility basement level) Generator Room (for east wing), had an annual inspection tag dated 2009.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the missing monthly and annual fire extinguisher inspections.

Based on observation and interview, it was determined the facility failed to maintain designated no-smoking areas in one instance, affecting one of three floors in this component.

Findings include:

1. Observation on August 5, 2013, at 11:46 AM revealed discarded cigarette butts in an open trash can, which contained combustible trash, at the rear terrace. This outdoor area has a sign indicating that it is a no smoking area. This is a repeat deficiency that was originally cited during the 2012 State Licensure survey.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the terrace area was not an authorized smoking area.

Based on observation and interview, it was determined the facility failed to maintain key components of the heating, ventilation and air conditioning (HVAC) system in one instance, on one of three floors within the component.

Findings include:

1. Observation on August 5, 2013, at 11:27 AM revealed the 1st floor (facility basement level) High Voltage Electrical Vault had a duct penetrating through to the adjoining room, which lacked a fire damper.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the HVAC deficiency.

Based on observation and interview, it was determined the facility failed to maintain the installed essential electrical system in one instance, affecting three of three floors in this component.

Findings include:

1. Observation on August 5, 2013, at 10:07AM, revealed the emergency generator annunciator panel, located near the second floor nurses station, was not working.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the east wing emergency generator annunciator panel was inoperative.

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 did not conform to applicable Federal, State and local laws and regulations.

Findings include:

1. Review of documentation on August 5, 2013, at 9:18 AM revealed the facility did not have accurate floor plans readily available identifying the locations of fire rated enclosures, shaft walls, horizontal exits, required exits, smoke barrier walls, and fire barrier walls in this component.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed accurate plans were not available.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems in one instance, affecting one of three floors in this component.

Findings include:

1. Observation on August 5, 2013, at 10:18 AM revealed an open electrical conduit with exposed wire ends, located above the corridor ceiling, near second floor room 219.

Exit interview with the facility administrator and facility representative #1 on August 5, 2013, between 12:30 PM and 12:45 PM confirmed the exposed wires were not terminated.