QA Investigation Results

Pennsylvania Department of Health
GEISINGER GASTROENTEROLOGY AND ENDOSCOPY CENTER - LEWISTOWN
Building Inspection Results

GEISINGER GASTROENTEROLOGY AND ENDOSCOPY CENTER - LEWISTOWN
Building Inspection Results For:


There are  17 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - MAIN BUILDING 01 Component - 01

Facility ID# 05731500
Component 01
Building 01

Based on a Relicensure Survey completed on April 15, 2019, it was determined that Geisinger Gastroenterology and Endoscopy Center - Lewistown was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.

This is a three-story, Type III (200), unprotected ordinary structure, which is fully sprinklered.



Plan of Correction:




28 Pa. Code 569.2 STANDARD
Building Construction Type and Height

Name - MAIN BUILDING 01 Component - 01
Building Construction Type and Height
Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively.


Construction Type
1 I (442), I (332), II (222), Any number of stories
II (111), III (211), IV (2HH), non-sprinklered or sprinklered
V (111)

2 II (000), III (200), V (000) One story non-sprinklered
Any number of stories sprinklered

Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met:
1. Such levels are under the control of the ambulatory health care occupancy.
2. Hazardous spaces are protected per section 8.7.
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2

Observations:

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed margins, and to maintain the rating of stairtower walls, on one of three floors within the component.

Findings include:

1. Observation on April 15, 2019, between 11:10 AM and 11:20 AM, revealed stairtower doors had gaps greater than an eighth of an inch, at the following locations:

a. 11:10 AM, front stairtower by Recovery Bay 1;
b. 11:20 AM, rear stairtower door.

Interview with the Facilities Manager on April 15, 2019, at 11:20 AM confirmed stairtower doors had gaps greater than 1/8 inch.


2. Observation on April 15, 2019, at 11:15 AM revealed M/C cables penetrating the front stairtower wall by Recovery Bay 1 had been sealed with orange foam.

Interview with the Facilities Manager on April 15, 2019, at 11:15 AM confirmed the penetration was sealed with an unapproved substance.







Plan of Correction:

1.
a) Maintenance Facilities Manager will have the front stair tower door by Recovery Bay # 1 replaced with a 1 hour hollow metal fire rated door. The existing door closure and hardware on this door will also be replaced with new fire rated closure and hardware. Facilities Manager will contact an outside vendor to get the doors ordered by May 8, 2019. Once the new 1 hour hollow metal fire rated door and new fire rated closure and hardware are properly installed they will be asset / PM tagged in our Archibus system and a quarterly preventative inspection will be set up for the next year to insure the door properly closes, latches and gaps are correct. If no issues are found, we will then go to an annual inspection. The preventative inspections will be documented in the Archibus System. Any noted repairs during the inspection will be completed immediately and documented in the Archibus System.


b) Maintenance Facilities Manager will have the rear stair tower door replaced with a 1 hour hollow metal fire rated door. The existing door closure and hardware on this door will also be replaced with new fire rated closure and hardware. Facilities Manager will contact an outside vendor to get the doors ordered by May 8, 2019. Once the new 1 hour hollow metal fire rated door and new fire rated closure and hardware are properly installed they will be asset / PM tagged in our Archibus system and a quarterly preventative inspection will be set up for the next year to insure the door properly closes, latches and gaps are correct. If no issues are found, we will then go to an annual inspection. The preventative inspections will be documented in the Archibus System. Any noted repairs during the inspection will be completed immediately and documented in the Archibus System.



2. General Maintenance, Maintenance Mechanic personnel will remove the unapproved orange foam and use an approved through wall penetration fire stop system to seal the M/C cables through the front stair tower wall, in Recovery Bay #1. The system will be in accordance with 3M UL System W-L-3347 to maintain the two-hour fire separation rating. General maintenance, Maintenance Mechanic personnel will inspect the fire barriers in this suite on a semiannual basis and report finding back to the Facilities Manager. Any penetrations will be fixed and or sealed using the proper UL system immediately. This will be completed by April 30, 2019.



28 Pa. Code 569.2 STANDARD
Electrical Systems - Maintenance and Testing

Name - MAIN BUILDING 01 Component - 01
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:

Based on document review, observation and interview, it was determined the facility failed to conduct required testing of receptacles in patient care ares, in one of one smoke zone.
Findings include:
1. Review of documentation on April 15, 2019, between 10:00 AM and 11:00 AM revealed the required annual inspection of receptacles, in Patient Care Areas, was not performed.
Interview with the Facilities Manager on April 15, 2019, at 11:00 AM confirmed the annual receptacle testing was not performed.





Plan of Correction:

1. All outlets if not hospital grade will be replaced with hospital grade outlets. All outlets at the patient bed location, and where deep sedation or general anesthesia is administered will be tested initially and then tested per the manufacture recommendations thereafter. The outlets polarity, tension and ground will be tested during these tests. General maintenance, Maintenance Mechanic personnel will perform the testing. The testing will be recorded and documented in our Archibus system. Any outlets that fail will be replaced immediately and will be documented in our Archibus system. All finding will be reported to the Facility Manager for review of compliance. This will be completed before May 31, 2019.