QA Investigation Results

Pennsylvania Department of Health
ENCOMPASS HEALTH REHABILITATION HOSPITAL OF SEWICKLEY, LLC
Building Inspection Results

ENCOMPASS HEALTH REHABILITATION HOSPITAL OF SEWICKLEY, LLC
Building Inspection Results For:


There are  12 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - MAIN BUILDING Component - 01

Facility ID# 234101
Component 01
East Building

Based on a Relicensure Survey completed on February 27, 2017, it was determined that Healthsouth Rehabilitation Hospital of Sewickley was not in compliance with the following requirements of the Life Safety Code for an existing Acute and Ambulatory health care occupancy.

This is a four-story, Type III (200), unprotected ordinary building, without a basement, that is fully sprinklered.








Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - MAIN BUILDING Component - 01
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
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.


Observations:

Based on observation and interview, it was determined the facility failed to maintain building construction requirements throughout the facility.

Findings include:

1. Observation on February 27, 2017, at 9:00 a.m., revealed the facility was constructed as a three story, Type III (200), unprotected ordinary structure. This exceeds the maximum allowable story height for this type of construction.

Interview with the Director of Plant Operations on February 27, 2017, at 2:30 p.m., confirmed the construction type deficiency.








Plan of Correction:

As directed by the site surveyor on 02/27/2017, HealthSouth Rehabilitation Hospital of Sewickley would like to request an FSES Survey to address the identified deficiency.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - MAIN BUILDING 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 documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances on two of four floors.

Findings include:

1. Review of documentation on February 27, 2017, revealed the following automatic sprinkler system maintenance deficiency:

a) 10:25 a.m., the sprinkler heads in the kitchen dishwashing area were loaded with lint, affecting the spray pattern.
b) 11:03 a.m., the automatic sprinkler gauges were more than five years old. The facility could not provide documentation that the gauges had been changed or recalibrated within five years.
c) 11:20 a.m., three sprinkler heads in the speech therapy corridor, near room 2513, were loaded with lint.

Interview with the Director of Plant Operations on February 27, 2017, at 2:30 p.m., confirmed the automatic sprinkler system deficiencies.



Plan of Correction:

A.) The sprinkler gauges were cleaned with a soft bristly brush and forced air to eliminate the lint in the sprinkler head located in the kitchen/dishwashing area and corridor in the therapy hallway near room 25-13 on 02/27/2017.

A preventative maintenance (PM) work order has been set up in the hospital's computerized maintenance management system (CMMS) to prompt annual floor-level inspection of components of the sprinkler system inspection including all sprinkler heads throughout the hospital; the first such work order was generated on 3/1/2017 and was completed on 3/8/2017. This work order will be assigned to and completed by the Director of Plant Operations. Corrective maintenance work orders will be generated for any deficiencies identified during inspection.

In order to insure ongoing compliance, the Director of Plant Operations will report to the hospital's Safety and Risk Committee on a quarterly basis the percent completion of all Tier-1 PM work orders. The threshold of compliance is 100%. Any deviations will be addressed by the Director of Plant Operations with hospital leadership.

B.) The pressure gauge cited was replaced by an outside contractor (Firefighters Sales and Service Company) on 03/06/2017. A label stating, "This gauge to be replaced on or before 2/1/2022 has been affixed to the new gauge.

The sprinkler systems are inspected and tested semi-annually by a contracted service vendor who will verify and document the condition and age of system pressure gauges as part of each inspection. Any defective gauges or those found to be approaching the end of their five-year life expectancy will be replaced at the time of inspection.

The Director of Plan Operations will be responsible for monitoring sprinkler system test results and for ensuring follow-up action on identified issues.


NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie

Name - MAIN BUILDING Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier wall in one instance, on one of four floors.

Findings include:

1. Observation on February 27, 2017, at 11:20 a.m., revealed an unsealed bundle of data wires penetrating the second floor smoke barrier wall, above the corridor doors, near room 2311.

Interview with the Director of Plant Operations, on February 27, 2017, at 2:30 p.m., confirmed the unsealed penetration.






Plan of Correction:

On 02/27/2017, the smoke barrier penetrations located on the second floor near room 23-11 were sealed on both sides using approved intumescent sealant manufactured by Hilti Firestop Systems Inc. The product used was Hilti FS-One which was installed by in-house maintenance staff to a >5/8 inch depth on both side of the wall sealing an opening of approximately 2 inches in diameter and containing six Cat 5 computer cables with PVC insulation and jacket.

The above described installation constitutes a System No. W-L-3065 per documentation from Hilti Firestop Systems, Inc. This system allows 45% fill of cables in the opening and can be used in 1 or 2 hour fire rated wall assemblies.

A preventative maintenance (PM) work order has been set up in the hospital's computerized maintenance management system (CMMS) to prompt semi-annual inspection of all smoke and fire barriers throughout the hospital. These work orders are classified as a Tier-1 work order in the CMMS designating these inspections as compliance-related. Inspections will be assigned to and completed by the Director of Plant Operations. Corrective maintenance work orders will be generated for any deficiencies identified during the inspection; the first such work order was generated on 3/1/2017 and was completed on 3/8/2017.

In order to ensure ongoing compliance, the Director of Plant Operations will report to the hospital's Safety and Risk Committee on a quarterly basis the percent completion of all Tier-1 PM work orders. The threshold of compliance is 100%. Any deviations will be addressed by the Director of Plant Operations with hospital leadership.




Initial Comments:
Name - BUILDING 02 Component - 12

Facility ID# 234101
Component 12
Pool Building

Based on a Relicensure Survey completed on February 27, 2017, it was determined that Healthsouth Rehabilitation Hospital of Sewickley was not in compliance with the following requirements of the Life Safety Code for an existing Acute and Ambulatory health care occupancy.

This is a one-story, Type IV (2HH), Heavy Timber Building, with a basement, that is fully sprinklered.









Plan of Correction:




NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - BUILDING 02 Component - 12
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 and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance affecting the entire building.

Findings include:

1. Observation on February 27, 2017, at 11:03 a.m., revealed the automatic sprinkler gauges were more than five years old. The facility could not provide documentation that the gauges had been changed or recalibrated within five years.

Interview with the Director of Plant Operations on February 27, 2017, at 2:30 p.m., confirmed the automatic sprinkler system gauges required recalibration or replacement.







Plan of Correction:

The pressure gauge cited was replaced by an outside contractor (Firefighters Sales and Service Company) on 03/06/2017. A label stating, "This gauge to be replaced on or before 2/1/2022 has been affixed to the new gauge.

The sprinkler systems are inspected and tested semi-annually by a contracted service vendor who will verify and document the condition and age of system pressure gauges as part of each inspection. Any defective gauges or those found to be approaching the end of their five-year life expectancy will be replaced at the time of inspection.

The Director of Plan Operations will be responsible for monitoring sprinkler system test results and for ensuring follow-up action on identified issues.



Initial Comments:
Name - BUILDING 03 Component - 23

Facility ID# 234101
Component 23
Education Building

Based on a Relicensure Survey completed on February 27, 2017, it was determined that Healthsouth Rehabilitation Hospital of Sewickley was not in compliance with the following requirements of the Life Safety Code for an existing Acute and Ambulatory health care occupancy.

This is a one-story, Type II (222), fire resistive building, without a basement, that is fully sprinklered.









Plan of Correction:




NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - BUILDING 03 Component - 23
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 and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance affecting the entire building.

Findings include:

1. Observation on February 27, 2017, at 11:03 a.m., revealed the automatic sprinkler gauges were more than five years old. The facility could not provide documentation that the gauges had been changed or recalibrated within five years.

Interview with the Director of Plant Operations on February 27, 2017, at 2:30 p.m., confirmed the automatic sprinkler system gauges required recalibration or replacement.




Plan of Correction:

The pressure gauge cited was replaced by an outside contractor (Firefighters Sales and Service Company) on 03/06/2017. A label stating, "This gauge to be replaced on or before 2/1/2022 has been affixed to the new gauge.

The sprinkler systems are inspected and tested semi-annually by a contracted service vendor who will verify and document the condition and age of system pressure gauges as part of each inspection. Any defective gauges or those found to be approaching the end of their five-year life expectancy will be replaced at the time of inspection.

The Director of Plan Operations will be responsible for monitoring sprinkler system test results and for ensuring follow-up action on identified issues.



Initial Comments:
Name - BUILDING 04 Component - 45

Facility ID# 234101
Component 45
North Court Building

Based on a Relicensure Survey completed on February 27, 2017, it was determined that Healthsouth Rehabilitation Hospital of Sewickley was not in compliance with the following requirements of the Life Safety Code for an existing Acute and Ambulatory health care occupancy.

This is a two-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.








Plan of Correction:




NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - BUILDING 04 Component - 45
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 and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance affecting the entire building.

Findings include:

1. Observation on February 27, 2017, at 11:03 a.m., revealed the automatic sprinkler gauges were more than five years old. The facility could not provide documentation that the gauges had been changed or recalibrated within five years.

Interview with the Director of Plant Operations on February 27, 2017, at 2:30 p.m., confirmed the automatic sprinkler system gauges required recalibration or replacement.




Plan of Correction:

The pressure gauge cited was replaced by an outside contractor (Firefighters Sales and Service Company) on 03/06/2017. A label stating, "This gauge to be replaced on or before 2/1/2022 has been affixed to the new gauge.

The sprinkler systems are inspected and tested semi-annually by a contracted service vendor who will verify and document the condition and age of system pressure gauges as part of each inspection. Any defective gauges or those found to be approaching the end of their five-year life expectancy will be replaced at the time of inspection.

The Director of Plan Operations will be responsible for monitoring sprinkler system test results and for ensuring follow-up action on identified issues.