QA Investigation Results

Pennsylvania Department of Health
CROZER KEYSTONE HOSPICE
Building Inspection Results

CROZER KEYSTONE HOSPICE
Building Inspection Results For:


There are  11 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - HOSPICE Component - 01

Facility ID# 156799
Component 01
Crozer Keystone Hospice

Based on a Relicensure Survey completed on February 13, 2019, it was determined that Crozer Keystone Hospice was not in compliance with the following requirements of the Life Safety Code for an existing Hospice health care occupancy.

This is a three-story, Type II (222), fire-resistive construction, with a basement, which is fully sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Cooking Facilities

Name - HOSPICE Component - 01
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:

Based on observation and interview, it was determined the facility failed to ensure the kitchen suppression system was inspected at required intervals, affecting one of two inspections.

Findings include:

1. Observation made on February 13, 2019, at 11:15 am, revealed the facility could not produce documentation showing that a kitchen suppression system inspection was performed within 6 months of the June 2018 inspection.

Interview at the exit conference with the Administrator and the Maintenance Director on February 13, 2019, at 12:00 pm, confirmed the missing documentation.






Plan of Correction:

inspection was scheduled immediately by the facility manager upon discovery of the lapse (2/14/19) inspection was completed on 2/28/19.

The measures our facility is taking to ensure the deficiency does not recur is our inspection will be scheduled in 6 month intervals to maintain compliance. The Facility manager will audit bi annually and report to the VP of facilities.
*The Facilities Manager is ultimately responsible to ensure compliance with this corrective action.



NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - HOSPICE Component - 01
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on document review and interview, it was determined the facility failed to ensure required fire alarm inspections were conducted within the previous twelve months, affecting 1 of two inspections.

Findings include:

1. Document review on February 13, 2019, at 10:30 am, revealed the facility could not produce documentation that a semi-annual fire alarm inspection had been performed within 6 months of the annual fire alarm inspection conducted June 2018.

Interview at the exit conference with the Maintenance Director on February 13, 2019, at 12:00 pm, confirmed a semi-annual fire alarm inspection had not been performed.





Plan of Correction:

Upon discovery of the lapse, Inspection was scheduled immediately with our vendor, (2/14/19)
by the facility manager. The facility has a list of all points on the fire system and will complete visual inspection in the appropriate time frame (in this case semi-annually). work orders will be recurring in the system for facility manager or mechanic to complete visual (scheduled for and completed on 3/29/19 for correction by facility manager)

The facility manager will audit quarterly to maintain compliance and will report to the VP of facilities.

*The Facilities Manager is ultimately responsible to ensure compliance with this corrective action.




NFPA 101 STANDARD
Smoke Detection

Name - HOSPICE Component - 01
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2

Observations:

Based on observation and interview, it was determined the facility failed to maintain the proper operation of smoke detectors, affecting one of three levels.

Findings include:

1. Observation on February 13, 2019, between 8:45 am and 8:50 am, revealed missing ceiling tiles, which may delay activation of smoke detectors, in the following locations:

a. 8:45 am, Basement maintenance shop;
b. 8:50 am, Basement storage room.

Interview at the exit conference with the Administrator and the Maintenance Director on February 13, 2019, at 12:00 pm, confirmed the missing ceiling tiles.






Plan of Correction:

Both Locations were issued work orders and completed (Work orders issued 2/15/19). These work orders were perfomed by the facility mechanic on duty. The deficiencies were corrected by re-cutting The 2x4 ceiling tiles that were not cut close enough to some ducting so we replaced the ceiling tiles to make the gaps tighter and then sealed them with fire caulking. Tiles replaced 2/16/19, fire caulking completed 3/1/19

This will be looked at daily as part of our building rounds completed by our on shift mechanics.

This will be audited by the facility manager and reported to the VP of facilities.

*The Facilities Manager is ultimately responsible to ensure compliance with this corrective action.



NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - HOSPICE Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation, document review and interview, it was determined the facility failed to conduct required inspections of the automatic sprinkler system, affecting the entire facility.

Findings include:

1. Document review on February 13, 2019, at 10:40 am, revealed the facility could not provide documentation showing the following required sprinkler inspections had been performed:

a. 3rd quarter 2018;
b. 4th quarter 2018.

Interview at the exit conference with the Administrator and the Maintenance Director on February 13, 2019, at 12:00 pm, confirmed the missing quarterly inspections.


2. Observation on February 13, 2019, at 10:50 am, revealed the sprinkler gauges were dated 2013, exceeding the 5-year service interval for replacement or recalibration.

Interview at the exit conference with the Administrator and the Maintenance Director on February 13, 2019, at 12:00 pm, confirmed the gauges were beyond the five (5) year service interval.





Plan of Correction:

Upon discovery of the lapse the facility manager scheduled a quarterly inspection (2/15/19) and inspection for 1st quarter 19 completed on 3/28/19 by service vendor.

The facility sprinkler gauges were inspected as part of the quarterly inspection on 3/28/19 and the tags have been made current.

The facility manager is responsible for scheduling of sprinkler inspections and will schedule these in the proper time frame of once per quarter to be in compliance.


This will be audited by the facility manager on a quarterly basis and reported to the VP of facilities

*The Facilities Manager is ultimately responsible to ensure compliance with this corrective action.



NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste

Name - HOSPICE Component - 01
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:

Based on documentation review and interview, it was determined the facility failed to maintain required testing of the emergency generator, affecting the entire facility.

Findings include:

1. Document review on February 13, 2019, at 11:30 am, revealed the facility could not produce documentation showing a 36 month, 4-hour exercise of the emergency generator had been performed.

Interview at the exit conference with the Administrator and the Maintenance Director on February 13, 2019, at 12:00 pm, confirmed the facility could not produce documentation for the required exercise.





Plan of Correction:

Upon discovering we could not locate the documentation (2/14/19) Facility manager located the generator book, the last 36 month 4 hour load test was performed on 8/26/16 and 8/30/16.

The facility manager has pre scheduled the next 4 hour load test for 8/2019

The facility manager will audit generator logs and report to the VP of facilities

*The Facilities Manager is ultimately responsible to ensure compliance with this corrective action.