HospitalInspections.org

Based on observation, document review, and interview, it was determined that the facility failed to maintain the fire resistive integrity of the building construction within one of five buildings on this campus.

Findings include:

1. Observation made on January 14, 2013, at approximately 12:00 pm, revealed 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. Emergency shoring was in place at the time of inspection and an asbestos abatement had taken place removing pipe insulation within this area.

Interview at the time of the exit conference with the the Property Manager on January 14, 2013, at 3:40 pm, confirmed the above condition of the structural column.

2. Documentation provided by the facility dated June 7, 2012, noted the following conclusions, "Based on visual review of the exposed structural elements, we observed several conditions that appear to be an immediate safety hazards.We also observed several conditions as noted above that may deterioriate further and become safety hazards if not addressed." The report documents the following observations:

a. Major deterioration of the steel reinforcing bars located throughout the underside of the concrete slab due to water leakage over time
b. Spalled concrete from the underside of the slab, columns, and concrete foundation walls
c. Deterioration throughout the steel beams and girders

Interview at the time of the exit conference with the Property Manager on January 14, 2013, at 3:40 pm, confirmed the facility will provide documentation to verify the above structrual evaluation occurred.

3. Observation made on January 14, 2013, at approximately 12:10 pm, revealed the second floor, where the Boilers are housed, noticably vibrated throughout the operation of air compressor NB 131961 labeled as "other storage."

Interview at the time of the exit conference with the the Property Manager and Maintenance Personnel on January 14, 2013, at 3:40 pm, confirmed there was audible indication and a slight vibration of the floor when the air compressor was engaged.

Based on observation and interview, it was determined that the facility failed to maintain protection of components of the heating, ventilating, and air conditioning (HVAC) equipment in one of five buildings within this campus.

Findings include:

Observation on January 14, 2013, revealed inside the Main Building's main electrical panel for HVAC equipment, several breakers were tagged out of service due to a build-up of steam inside piping located above the panel.

Interview at the time of the exit conference with the Property Manager and Maintenance Personnel on January 14, 2013, at 3:40 pm, confirmed there was damage to the main breaker panel.

28 PA Code ? 103.4(3). Responsibility of the Licensee

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.

(b) 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, document review, and interview, it was determined that the following items did not conform to applicable Federal, State and local laws and regulations in three of five buildings within this campus.

Findings include:

1. Observation on January 14, 2013, between 1:30 pm and 3:40 pm, revealed 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. The "emptying" of the water was documented and reviewed in log books dating from October 1, 2010, through to January 5, 2013. Both areas are currently unoccupied.

Interview at the time of the exit conference with the Property Manager and Maintenance Personnel on January 14, 2013, at 3:40 pm, confirmed there were water leaks inside the areas listed above.

2. Observation on January 14, 2013, at approximately 12:00 pm, revealed there were areas where insulation was loosely hanging and cut along piping inside the Boiler House that supports the Marion Pavilion, North, and Main Buildings. Documentation provided by the facility dated April 16, 2012, indicates 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.

Interview at the time of the exit conference with the Property Manager on January 14, 2013, at 3:40 pm, confirmed there were unsecured and incomplete pieces of insulation along piping inside the Boiler House.

Based on document review, observation, and interview, it was determined that the facility failed to perform required testing of the emergency generators on four of four emergency generators within this campus.

Findings include:

Document review made on January 14, 2013, between 12:00 pm and 1:30 pm, revealed the facility has a total of four emergency generators. Documentation was unavailable verifying weekly testing of the emergency generators from March 2012 through January 14, 2013. In addition, the following items were noted:

a. Marion Pavilion - monthly testing from March 15, 2012, through January 13, 2013, times indicated the generator had been tested under full load for 1/2 hour, yet the meter readings did not concur (eg. 516, 517, 517, 518, 518, 522, 525, 525, 526, 526).

b. North Building - monthly testing from March 6, 2012, through December 16, 2012, times indicated the generator had been tested under full load for 1/2 hour, yet the meter readings did not concur (eg. 425.3, 425.9, 426.2, 426.7, 427.5, 427.7 - 432.9, 433.3).

c. Main Building - monthly testing from October 3, 2012, through January 13, 2013, indicated the generator had not been tested under load for a minimum of 1/2 hour on a consistent basis. In addition, the meter readings were as follows (eg.189.7, 190.1, 190.5, 191).

d. Broad Street Building - monthly testing from March 20, 2012, through December 15, 2012, times indicated the generator had been tested under full load for 1/2 hour, yet the meter readings did not concur (720.3, 720.4, 721.1, 721.5, 722.1, 722.5, 722.9).

Interview at the time of the exit conference with the Property Manager and Maintenance Personnel on January 14, 2013, at 3:40 pm, confirmed the above items during document review.

Based on observation and interview, it was revealed that the facility failed to maintain protection of electrical equipment in one location of one main electrical panel within this campus.

Findings include:

Observation made on January 14, 2013, between 1:30 pm and 3:40 pm, revealed approximately 3 inches of standing water on the floor beneath the main electrical panels inside the main electrical room, 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.

Interview at the time of the exit conference with the Property Manager and Maintenance Personnel on January 14, 2013, at 3:40 pm, confirmed the accumulation of water beneath the main electrical panel.