Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on February 13, 2024, at Penn Highlands Brookville, it was determined there were no deficiencies identified with the requirements of 42 CFR 482.15.
Plan of Correction:
Initial Comments:
Name - MAIN Component - 01
Facility ID #28050101
Component 01
Main Building/Patient Tower
Based on a Recertification Survey completed on February 13, 2024, it was determined that Penn Highlands Brookville was not in compliance with the requirements of the Life Safety Code for an existing critical access health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 485.623 (d).
This is a five-story, Type II (222), fire resistive building, with a partial basement, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Cooking Facilities
Name - MAIN 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 document review and interview, the facility failed to maintain cooking facilities in one of one main kitchen.
Findings include:
Document review on February 13, 2024, at 9:25 a.m., revealed the facility could not provide documentation for one of two semi-annual kitchen exhaust hood and duct cleanings. The last documented cleaning occurred on July 27, 2023.
Interview with the maintenance technician on February 13, 2024, at 9:25 a.m., confirmed the kitchen hood/duct cleaning deficiency.
Plan of Correction:The Maintenance Director, or designee, will contact the contract service to schedule the semi-annual kitchen exhaust hood and duct cleaning. The Maintenance Director or designee will re-educate contracted service of requirement for semi-annual inspection of kitchen exhaust hood and duct cleaning by March 31, 2024.
The Maintenance Director will validate that the semi-annual kitchen exhaust hood and duct cleaning is on a semi-annual preventative maintenance schedule going forward.
Initial Comments:
Name - BLDG. 02 Component - 03
Facility ID #28050101
Component 03
1963 Building and O.R. Building
Based on a Recertification Survey completed on February 13, 2024, it was determined that Penn Highlands Brookville was not in compliance with the requirements of the Life Safety Code for an existing critical access health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 485.623 (d).
This is a three-story, Type II (222), fire resistive building, with a partial basement, that is partially sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - BLDG. 02 Component - 03
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, the facility failed to meet building construction type requirements for one of three building levels.
Findings include:
Observation on February 13, 2024, at 9:13 a.m., revealed the ground floor MRI life safety drawings identified a two-hour rated wall separation to the pet scan area. The fire door, a part of the two-hour rated separation, was removed.
Interview with the maintenance director on February 13, 2024, at 9:13 a.m., confirmed the deficiency.
Plan of Correction:The Maintenance Director will have the 2 hour fire rated door reinstalled on the ground floor MRI hallway that has been approved by plan review by April 30, 2024.
NFPA 101 STANDARD
Exit Signage
Name - BLDG. 02 Component - 03
Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)
Observations:
Based on observation and interview, the facility failed to maintain exit signage requirements for one of over ten exit signs.
Findings include:
Observation on February 13, 2024, at 9:26 a.m., revealed the basement exit sign light was not functioning at the time of the survey.
Interview with the maintenance technician on February 13, 2024, at 9:26 a.m., confirmed the exit sign was not illuminated.
Plan of Correction:The Maintenance Director, or Designee, will install a new light bulb in the basement exit sign. The Maintenance Director will add the basement exit light to the monthly check list and educate staff on this addition by March 31, 2024.
NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie
Name - BLDG. 02 Component - 03
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, the facility failed to maintain smoke barrier wall requirements for two of three building levels.
Findings include:
Observation on February 13, 2024, between 9:09 a.m. and 10:55 a.m., revealed the following areas had open ceiling tiles that would allow the passage of smoke in the event of an emergency:
A. (9:09 a.m.) Basement boiler room;
B. (10:55 a.m.) First floor elevator room.
Interview with the maintenance director on February 13, 2024, at 10:55 a.m., confirmed the deficiencies.
Plan of Correction:A. Replace the ceiling tile in the basement boiler room.
B. Replace the ceiling tile in first floor elevator room.
The Maintenance Director, or designee, will educate Maintenance Department staff to include these areas on the ceiling tile check with monthly safety rounds. Education will be complete by March 31, 2024.
NFPA 101 STANDARD
Electrical Systems - Other
Name - BLDG. 02 Component - 03
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Based on observation and interview, the facility failed to meet electrical system requirements for three of over ten electrical panels.
Findings include:
Observation on February 13, 2024, at 9:44 a.m., revealed the stairwell 11 electrical closet had open conductor slots in panels X, B, and C.
Reference: NFPA 70-408.7
Interview with the maintenance director on February 13, 2024, at 9: 44 am., confirmed the deficiencies.
Plan of Correction:The Maintenance Director, or Designee, will replace covers on the conductor slots in panels X, B, and C. The Maintenance Director will re-educate maintenance staff on proper electrical safety and best practices for electrical panel safety by March 31, 2024.
NFPA 101 STANDARD
Electrical Systems - Receptacles
Name - BLDG. 02 Component - 03
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)
Observations:
Based on observation and interview, the facility failed to maintain receptacle requirements on two of three building levels.
Findings include:
Observation on February 13, 2024, between 9:01 a.m. and 10:40 a.m., revealed the following receptacles, located within six feet of a water source, were not protected by a ground fault circuit interrupter (GFCI) :
A. (9:01 a.m.) Basement boiler room sump pump area;
B. (10:40 a.m.) Second floor rehab sink area.
Interview with the maintenance technician and maintenance director on February 13, 2024, at 10:40 a.m., confirmed the areas were not protected by GFCIs.
Plan of Correction:A. Install GFCI in the basement boiler room sump pump area.
B. Install GFCI in the second floor rehab sink area.
The Maintenance Director, or designee, will educate the Maintenance Department on using appropriate GFCI receptacles in designated areas by March 31, 2024. Appropriate GFCI receptacle use will be validated during safety rounds.
Initial Comments:
Name - MOB BUILDING Component - 99
Facility ID #28050101
Component 99
Medical Office Building
Based on an unannounced Medicare Recertification Survey completed on February 13 2024, at Penn Highlands Brookville (Outpatient Services), it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing acute care health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 482.41(b).
This is a two-story, Type II (222), protected, non-combustible building, that is fully sprinklered.
Plan of Correction:
|