HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to ensure that common fire walls and doors are properly inspected and maintain a fire resistive rating in one of eight levels within this component.

Findings include:

Observation made on April 8, 2013, at 11:03 am, revealed that on the first floor Broad Street Bldg Pharmacy above the ceiling, there was a penetration of the common fire wall by Armor cable that lack fire proofing and a penetration by data wires that was sealed by a non rated combustible foam insulation.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unsealed and improperly sealed penetrations of the common wall in the pharmacy.

Based on observation and interview, it was determined that the facility failed to ensure that building construction maintains its fire resistance rating in two of eight levels within this component.

Findings include:

1. Documentation reviewed and observations on April 8, 2013, at 10:10 am, revealed a complaint report dated January 14, 2013, indicated the following conditions in the boiler house:

a. The physical structure of the support columns on the lower level of the Boiler House shows evidence of disintegration. There was a partially exposed steel column encased in concrete, supporting the Boilers above. During the recertification survey, observations noted the deteriorating concrete slab and reinforcement bars were removed and a new concrete column was poured. The column was still partially encased in a temporary wooden cast form.
b. There was Major deterioration of the steel reinforcing bars located throughout the underside of the concrete slab due to water leakage over time; spalled concrete from the underside of the slab, columns, and concrete foundation walls; and deterioration throughout the steel beams and girders. The deterioration throughout the steel beams and girders had not been repaired. The ceiling level steel beams and girders continued to be covered in rust. The Facility Representatives shall provide a written scope of work completed in the Boiler House.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the above conditions.

Based upon observation and interview, it was determined the facility failed to ensure the corridor walls were constructed and maintained with the required one half hour fire resistance rating in partially sprinklered construction in two of eight levels within this component.

Findings include:

1. Observations made on April 8, 2013, between 10:20 am and 1:10 pm, revealed in the following locations there were unsealed penetrations of the corridor walls above the ceiling in the non sprinklered sections of the building:

a. 10:20 am, first floor Broad Street Bldg corridor by the Life Administration offices, there were several penetrations and cutouts of the drywall by pipes, wires and Armor cable that were not sealed.
b. 1:10 pm, third floor Main building above the door to the data closet, unsealed blue data wire penetration.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the penetrations of the corridor walls.

Based on observation and interview, it was determined the facility failed to ensure corridor doors were smoke tight in their frames, there were no impediments to closing and latching
on five of eight levels within this component.

Findings include:

1. Observations on April 8, 2013, between 9:54 am and 1:30 pm, revealed the following corridor corridor doors failed to properly close and positively latch:

a. 9:54 am, second floor Broad Street building, Chop exam room 18.
b. 11:47 am, fist floor Broad Street building, Mercy Life area staff lounge door equipped with a self closure was held open with a wedge.
c. 1:10 pm, third floor Main building data closet, doors were equipped with closures and were dragging on the floor.
b. 1:30 pm, third floor Main building, patient care room 375.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the doors failed to close properly and the subsequent correction of item b deficiency at the time of the survey.

2. Observations on April 9, 2013, at 1:00 pm, revealed the ground floor Marion building, phone room corridor door requires adjustment to positively latch.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the doors failed to close properly.

Based on observation and interview, it was determined the facility failed to ensure vertical openings between floors were enclosed with the required fire resistive rated construction on five of eight levels within this component.

Findings include:

1. Observations on April 8, 2013, between 9:05 am and 2:35 pm, revealed the following unsealed vertical penetrations in the following locations:

a. 9:05 am, third floor Broad street Bldg, CHOP electrical closet, floor slab penetration behind the transformer and the wooden panel by a bundle of cables.
b. 11:50 am, fifth floor Main Bldg electrical closet, located next to exit stairway one, unsealed floor penetration of a wire bundle and BX cable.
c. 1:10 pm, third floor Main Bldg electrical closet located next to exit stairway one, unsealed floor penetration of a bundle of blue and white cable.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unsealed vertical penetrations in the above named locations.

2. Observation on April 8, 2013, at 2:35 pm, revealed on the second floor Marion building, old ICU, the building services shaft's fire resistive rated access door failed to close and positively latch.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the shaft access door failed to close properly.

3. Observations on April 9, 2013, between 10:25 am and 1:55 pm, revealed the following unsealed vertical penetrations in the following locations:

a. 10:25 am, second floor Main building, unsealed insulated pipe and PVC pipe penetrations inside building services shaft located behind the linen chute service room.
b. 1:55 pm, ground floor Main building, unsealed pipe penetrations inside building services shaft inside the old abandoned pharmacy.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unsealed vertical penetrations in the above named locations.

Based upon observation and interview, it was determined the facility failed to maintain the proper fire resistance rating of the smoke barrier walls in two of eight levels within this component.

Findings include:

1. Observations on April 8, 2013, between 11:08 am and 2:00 pm, revealed unsealed penetrations and penetrations sealed with an unknown substance in the smoke barrier walls at the following locations:

a. 11:08 am, first floor Broad Street Bldg Mercy Life reception office sides and rear walls of the smoke barrier above the ceiling, several penetrations by pipes, wires and cutouts of the walls.
b. 11:45 am, fourth floor Main building, BX wire penetration near room 471.
c. 12:00 pm, fourth floor Main building, black cable wiring near 459.
d. 1:35 pm, third floor Main building, unknown gray substance sealing gray wires in the smoke barrier wall at the administration area.
e. 2:00 pm, third floor Main building, white wire penetration near room 357.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unsealed or improperly sealed penetrations in the smoke barrier walls.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistance rating of hazardous areas on six of eight levels within this component.

Findings include:

1. Observations on April 8, 2013, between 11:45 am and 11:46 am, revealed the hazardous storage rooms door did not have self closing devices in the following areas:

a. 11:45 am, fourth floor Main building, room 478, no self closure and no fire resistive rating, room contained numerous cardboard boxes and did not have automatic sprinkler protection.
b. 11:46 am, fourth floor Broad street Bldg Mercy Life unit room # 163, labeled as Medical records room. The room contained file cabinets and file boxes.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the doors lacked self closures in the above named hazardous storage rooms.

2. Observations made on April 9, 2013, between 9:32 am and 9:36 am, revealed hazardous area doors that failed to positively latch when tested in the following locations:

a. 9:32 am, second floor Broad street Bldg CHOP Seaside soiled linen room.
b. 9:36 am, second floor Broad street Bldg CHOP telecom/storage room door which is accessible from the storage room, the door latch was taped over.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the doors to the storage rooms failed to positively latch when tested.


3. Observations made on April 9, 2013, at 1:07 pm, revealed hazardous areas that had unsealed pipe and conduit penetrations of walls in the Main Bldg Sub Basement machine room along the catwalk level that is next to the doors.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unsealed penetrations in the above named locations.


4. Observation made on April 9, 2013, at 11:57 am, revealed that on the Main Bldg Sub Basement Kindred storage room double door was wedged open with a piece of cardboard. The doors are equipped with a self closure.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the door to the storage room was wedged open and the subsequent correction of the deficiency during the time of the survey.


5. Observation made on April 9, 2013, at 1:41 pm, revealed that in the Basement level of the Main Bldg, there is a file storage room that is accessible from the corridor and a IT classroom. The door to the IT class room from the storage room is not rated and lacks a self closure. The file room contains files, and cabinets and loose papers. The room also had missing ceiling tiles near the end of the room. The file room does not reflect on the floor plans provided and may have being constructed without proper plan review and may have caused the path of egress to be extended out of the IT classroom as now one has to traverse a another room before reaching the exit access corridor or enter into the storage room to exit to the other corridor.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the non rated door and lack of closure on the file storage room and the possible egress issues out of the IT room that is adjacent to the file room.

Based on observation and interview, it was determined the facility failed to maintain the exit egress components with the required fire resistive rating in five of nine exit stairways.

Findings include:

1. Observations made on April 8, 2013, at 10:08 am, revealed unsealed penetrations of stair tower walls in the Broad street Bldg stair tower B on the middle of the steps between the first and second floor. There were several penetrations of the cinder block wall that are behind a metal cover plates.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unsealed penetrations in the above named locations.

2. Observations made on April 8, 2013, at 8:54 am, revealed stair tower doors that failed to positively latch when tested in the Broad street Bldg Penthouse stair tower B door.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the the stair tower doors failed to positively latch when tested in the above named locations.

3. Observations on April 9, 2013, at 11:15 am, revealed unsealed or improperly sealed pipe penetrations of the exit stairways at the first floor Marion building South exit stairway. The sprinkler pipe was stabilized with wooden shims and sealed with an unknown substance.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unsealed penetrations in the above named locations.

4. Observations on April 9, 2013 between 11:37 am and 11:45 am, revealed the following doors located within the stair way exit enclosure for stairway one did not close properly at the following locations:

a. 11:37 am, first floor Main building, computer training room door closure failed to close and positively latch the door due to the door dragging on the floor.
b. 11:45 am, first floor Main building, cross corridor double doors located at Mercy Administration, failed to close when released from the magnetic hold open, due to the door's hardware dragging on the floor.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the doors in the exit enclosure failed to close properly in the above named locations.

Based on observation and interview, it was determined the facility failed to ensure that exit access was arranged to be readily accessible and without obstructions on five of eight levels.

Findings include:

1. Observation made on April 8, 2013, at 10:42 am, revealed that on the first floor Broad
Street Bldg, the corridor door to the Stonehenge office suite has a dead bolt locking mechanism requiring a two step operation to egress out of the room.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the dead bolt lock and the two step operation to egress the room.

2. Observation on April 9, 2013, between 11:50 am and 12:00 pm, revealed the following impediments to egress in the exit stairway enclosures in the following locations:.

a. 11:50 am, first floor Main building stored inside the exit enclosure for exit stairway one there was a wooden pallet loaded with ice melt material.
b. 11:55 am, outside of Main building at exit stairway one means of egress to the public way there was construction equipment and materials stored in the pathway at the boiler building.
c. 12:00 pm, outside of Main building at exit stairway one, were the means of egress meets the public way there was a locked gate preventing access to the public way.
d. 1:10 pm, ground floor Main building, inside exit stairway two, there were two existing telephone equipment control panel boxes installed inside the stair. The bottom of one box was broken apart and numerous cables were draped down from the box. The box was cut into the stairway partition.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the impediments to the means of egress.

3. Observation on April 9, 2013, at 1:50 pm, on the ground floor Main building revealed in the abandoned pharmacy now utilized as a storage room, on one of the corridor doors, there was a combination latching device and a lockset installed on the door, which required two-hand operation to open the door.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the two step operation required to exit the room.

4. Observation made on April 9, 2013, at 10:14 am, revealed that on the ground floor Main Bldg exterior pathway to the public way by the loading dock there is a metal fence door with panic bar hardware that was chained shut. Next to the door is a sliding fence to the loading dock that is closed in the evenings, which restricts egress to public way incase of an emergency.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the fence door was chained shut and the restricted access to the public way during evening and night times.

Based on observation and interview it was determined that the facility failed to ensure exit signs are illuminated on two of eight levels within this component.

Findings include:

1. Observations made on April 8, 2013, between 10:10 am and 1:15 pm, revealed exit signs that had burnt out bulbs and were not illuminated in the following locations:

a. 10:10 am, Broad Street Building, first floor inside stair tower B, above the discharge door.
b. 1:15 pm, Broad Street Building, first floor inside stair tower C, above the discharge door.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the burnt out exit signs bulbs in the above named locations.

2. Observation made on April 9, 2013, at 11:50 am, revealed that on the Main Bldg Sub Basement laundry room, the exit sign over the middle double door exit was not illuminated.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the burnt out exit sign in the laundry room.

Based on observation and interview, it was determined that the facility failed to ensure that fire alarm system and its components are protected with a fire resistive rating on one of eight levels within this component.

Findings include:

Observation made on April 9, 2013, at 11:37 am, revealed that in the Main Building Sub Basement Fire Command control room above the ceiling, there were several penetrations of the cinderblock wall over the door frame and over the fire alarm panels by armor cables. The room is non sprinklered.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the penetrations of the fire command room walls.

Based on observation and interview, it was determined that the facility failed to ensure that smoke detectors are properly inspected and maintained free of obstructions on one of eight levels within this component.

Findings include:

Observation made on April 8, 2103, at 9:08 am, revealed that on the first floor Broad Street Bldg CHOP staff kitchen area, the ceiling mounted smoke detector had a paper decoration taped to the detector.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the paper decoration taped to the smoke detector.

Based on observation and interview, it was determined that the facility failed to ensure that
the automatic sprinkler system is maintained, smoke tight and sprinkler heads are free from obstructions on five of eight levels within this component.

Findings include:

1. Observation made on April 8, 2013, between 9:38 am and 1:45 pm, revealed missing and damaged ceiling tiles and openings in the monolithic ceilings which could delay operation of the sprinkler head in the following locations:

a. 9:38 am, second floor Broad Street Bldg CHOP telecom closet, missing and broken tiles and a twenty by twenty inch rectangular cut out of the drywall.
b. 9:42 am, second floor Broad Street Bldg CHOP electrical closet accessible from the lab, missing and broken tiles.
c. 10:31 am, first floor Broad Street Bldg Life office suite rear most office missing ceiling tiles.
d. 1:11 pm, ground floor Broad Street Bldg vacant Foot and Ankle Center, various tiles throughout the suite.
e. 1:16 pm, ground floor Broad Street Bldg, vacant MRI suite, missing tiles throughout the suite and a circular duct penetration of the tile in one of the MRI room.
f. 1:40 pm, ground floor Broad Street vacant ER suite, ceiling tiles throughout the suite.
g. 1:45 pm, ground floor Broad Street vacant Thomas Jefferson suite, missing ceiling tiles.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the missing, damaged ceiling tiles and monolithic ceilings were not smoke tight in the above named locations.

2. Observation made on April 8, 2013, at 11:26 am, revealed that on the first floor Broad street Mercy Care Life dining room, the double door IT closet has an incomplete dry wall section above the door frame. The closet is equipped with an upright sprinkler head but the length and width of the incomplete section could allow heat and smoke to escape the room and delay the activation of the sprinkler head.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the incomplete wall in the IT closet and the non smoke tight condition.

3. Observation made on April 8, 2013, at 11:40 am, revealed that on the first floor Broad Street Bldg Gym, the electrical closet had several penetrations and openings that were not sealed. The closet was not smoke tight which would delay the activation of the sprinkler head.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the electrical closet was not smoke tight.

4. Observation made on April 9, 2013, at 1:00 pm, revealed missing and damaged ceiling tiles and openings in the monolithic ceilings in the ground floor Marion Building, storage room located by the phone room.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the missing, damaged ceiling tiles and monolithic ceilings were not smoke tight in the above named locations.

Based on observation and interview, it was determined that the facility failed to ensure that heating, air conditioning and ventilating equipment is maintained in operable condition and components are in place on two of eight levels within this component.

Findings include:

1. Documentation reviewed and observations made on April 8, 2013, at 10:05 am, revealed a complaint report dated January 14, 2013, indicated the Main Building's main electrical panel for HVAC equipment had several breakers tagged out of service due to a build-up of steam inside piping located above the panel. During the recertification survey the following items were noted:

a. A mechanical engineering firm had been contracted to inspect the main breaker and had previously "tagged out" decommissioned circuits for equipment that was no longer in use.
b. A temporary tarp was installed above the electrical panel to protect the equipment from condensation water from dripping down onto the equipment.
c. A permanent system to prevent possible condensation leaks has been designed, but at the time of the survey was not installed. Facility Representatives estimated the installation date as June 30, 2013.
d. A mechanical engineer and the electrical panel manufacturer have joined in partnership to provide a proposal for a future modernization of the electrical equipment.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the above conditions.

2. Observation made on April 9, 2013, at 11:34 am, revealed that in the Main Bldg Sub Basement Fire control room, the HVAC ductwork grill was missing from the ceiling tile.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the missing grill in the fire control center.

Based on observation and interview, it was determined the facility failed to ensure the chute service opening room corridor doors were self closing in six of five chute service rooms.

Findings include:

Observation on April 8, 2013, at 1:20 pm, revealed on the third floor Main building the chute service room's door closure was broken.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the door was not self closing.

Based on observation and interview, it was determined that the facility failed to ensure that medical gas storage is properly inspected and maintained and secured on one of eight levels within this component.

Findings include:

Observation made on April 8, 2013, at 11:11 am, revealed that on the first floor Broad Street Bldg Mercy Care Triage room 107, there was an unsecured free standing "E" class oxygen cylinder next to the door to the waiting area.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unsecured freestanding oxygen cylinder in the triage room.

Based upon observation and interview, it was determined the facility failed to ensure that medical gas piping was properly labeled on one of eight levels.

Findings include:

Observation on April 8, 2013, at 2:10 pm, revealed on the third floor Main building the medical gas pipes were not labeled as they penetrated the corridor wall partition of room 357. Medical gas piping must be labeled on both sides of partitions penetrated by the piping.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the medical gas piping was missing the identifying labels.

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.

Findings include:

1. Observation and documentation reviewed on April 8, 2013, at 10:10 am, revealed a complaint survey report dated January 14, 2013, detailed the following :

a. 10:10 am, inside the Main Building, there were leaks from the ceiling that were being drained by various types of materials secured together, such as plastic troughs, extending from the ceiling into a sink inside the Speech Pathology room and the X-Ray room. As of this survey an asbestos abatement was completed, but the defective pipes had not been repaired. The water leaks were still being captured and drained with the plastic troughs and other devices.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed there were still water leaks inside the areas listed above.

2. Observation and documentation reviewed on April 8, 2013, at 10:20 am, revealed a complaint report dated January 14, 2013, detailed there were areas where insulation was loosely hanging and cut along piping inside the Boiler House that supports the Marion Pavilion and Main Buildings. Documentation provided by the facility dated April 16, 2012, indicated a limited asbestos survey was conducted in areas subject to renovation, repair, and plumbing work within the basement boiler room and determined that asbestos containing materials (ACM) exist and was listed as in good or fair condition and must be abated prior to commencement of work. At the time of this survey the abatement work was in progress and was scheduled to be completed on April 26, 2013.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the asbestos abatement was in the areas noted above had not been completed.

Based upon observation and interview, it was determined that the facility failed to maintain protection of electrical equipment and components, prevent the unauthorized use of electrical devices and remove temporary construction wiring on seven of eight levels.

Findings include:

1. Observations made on April 8, 2013, between 8:59 am and 1:35 pm, revealed the unauthorized use of powerstrips, extension cords and outlet multipliers in the following locations:

a. 8:59 am, third floor Broad Street Bldg office 322, portable heater plugged into a powerstrip.
b. 10:22 am, first floor Broad Street Bldg Administration suite corridor desk by the exit, extension cord in use to power office equipment.
c. 11:50 am, first floor Broad Street Bldg Mercy Life Nurse Managers Administrator Assistant office, portable heater plugged into a powerstrip.
d. 11:57 am, first floor Broad Street Mercy Life Director of Operations office, heater into a powerstrip.
e. 12:00 pm, fourth floor Main Building conference room a microwave powered from an extension cord.
f. 1:35 pm, third floor Main Building supervisor office, extension cord wire into gang box with electric outlets, powering office equipment.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the use of extension cords, powerstrips and outlet multipliers in the above named locations and the subsequent correction of item d during the time of the survey.

2. Observations made on April 8, 2013, between 9:04 am and 11:20 am, revealed unprotected junction boxes, electrical panels and exposed wires in the following locations:

a. 9:04 am, third floor Broad Street Bldg, CHOP electrical closet , electrical panel labeled E-3, inner cover face plate removed exposing the inner wiring of the panel.
b. 10:00 am, second floor Broad Street Bldg, CHOP double elevator lobby above ceiling, exposed wires protruding from conduit piping.
c. 10:50 am, first floor Broad Street Bldg Pharmacy above ceiling two thirds of the way from the fire wall, Romax cable with exposed wires.
d. 11:20 am, first floor Broad Street Bldg Mercy Life Dining room double door closet, open junction box connected to a Armor cable above the door frame.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unprotected boxes, panels and exposed wiring in the above named locations.

3. Observations made on April 8, 2013, between 9:43 am and 12:57 pm, revealed abandoned contractors temporary lighting in the following locations:

a. 9:43 am, second floor Broad Street Bldg CHOP electrical room accessible from the Lab, above the ceiling.
b. 12:57 pm, ground floor Broad Street Bldg, elevator lobby above the ceiling.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the abandoned contractors lighting in the above named locations.

4. Documentation reviewed and observations on April 8, 2013, at 10:10 am, revealed a complaint report dated January 14, 2013, indicated in the Main building inside the main electrical room (switchgear room) there was approximately three (3) inches of standing water on the floor beneath the main electrical panels, rated at 13,200 volts. This was seen from the back of the panel. An electric water pump had been installed in this area to remove the excess water. During the recertification survey, there was no standing water located beneath the electrical panel. A french drain had been constructed directing any water away from the electrical equipment into a drain pit that had a temporary pump installed. The facility was awaiting installation of permanent water pumps and alarms.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the above condition in the main electrical room.

5. Observations made on April 8, 2013, between 10:46 am and 1:03 pm, revealed damaged electrical outlets and light fixtures in the following locations:

a. 10:46 am, first floor Broad Street Bldg Snack Machine/Mail room behind the candy machine, electrical outlet is pushed into the drywall and lacks a protective face plate.
b. 1:03 pm, ground floor Broad Street Bldg Doctors office suite nearest to the elevator, closet that holds the generator day tank, wall mounted light fixture that was damaged and loose from the wall and exposing the inner wiring.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the damaged outlets and light fixtures in the above named locations.

6. Observation made on April 8, 2013, at 1:27 pm, revealed that on the ground floor of the Broad Street Bldg electrical Vault room, there was a penetration of the cinder block wall by ductwork that lacked a angular plate and was not sealed. The penetration pierced both sides of the cinder block.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the penetration of the electrical vault room.

7. Observations made on April 9, 2013, between 10:15 am and 1:29 pm, revealed the unauthorized use of powerstrips, extension cords and outlet multipliers in the following locations:

a. 10:15 am, second floor Main building in the electrical equipment closet located next to stairway one, extension cord powering electronic equipment.
b. 11:35 am, first floor Main building computer training room, several daisy chained surge protectors used to power computer equipment.
c. 11:57 am, Main Bldg Sub Basement Kindred storage room office area, refrigerator being powered by a orange extension cord and a microwave oven plugged into a powerstrip.
d. 1:09 pm, Main Bldg Sub Basement machine room, orange outlet multiplier powering Air Tank compressor units and a home made quad outlet box powering equipment.
e. 1:26 pm, Main Bldg Basement level Main IT room at the wall mounted IT rack, orange extension cord in use plugged into a UPS that was plugged into a powerstrip.
f. 1:29 pm, Main Bldg Basement level IT office area, by the fax machines, powerstrip plugged into a powerstrip.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed confirmed the use of extension cords, powerstrips and outlet multipliers in the above named locations.

8. Observation made on April 9, 2013, between 10:40 am and 1:45 pm, revealed unprotected electrical wring and connections in the following areas:

a. 10:40 am, first floor Main building elevator lobby, the lobby lighting circuit breaker panel cabinet had open areas exposing the electric connections. The cabinet was also unable to be closed and secured.
b. 11:25 am, first floor Main building kitchen dry storage area, there was an electrical wire hanging from the ceiling with exposed ends protected only with tape.
c. 1:05 pm, ground floor Main building, in room G-1 old Histology room, several open and protected electrical outlets and wiring protruding from demolished laboratory work stations.

Interview at the exit conference with the Director of Quality Management and the Property Manager on April 9, 2013, at 2:30 pm, confirmed the unprotected electrical wiring.