Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed December 21, 2023, at Good Shepherd Specialty Hospital, it was determined there were no deficiencies identified with the requirements of 42 CFR 482.15
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 53020100
Component 01
Main Building
Based on an unannounced Medicare Recertification Survey completed on December 21, 2023, it was determined that Good Shepherd Specialty Hospital, was not in compliance with 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 five story, Type II (222), fire resistive building, with a basement and miscellaneous rooftop mechanical spaces, that is partially sprinklered.
The Good Shepherd Specialty Hospital is located on the third floor of the Muhlenberg Campus of the Lehigh Valley Hospital.
Plan of Correction:
NFPA 101 STANDARD
Electrical Equipment - Power Cords and Extens
Name - MAIN BUILDING Component - 01
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Based on observation and interview, it was determined the facility failed to monitor the use of power taps in one of two smoke compartments.
Findings include:
1. Observation on December 21, 2023, at 11: 30 am, revealed various small appliances being powered by a power tap/surge protector in the staff lounge.
Interview with the administrator and Lehigh Valley Health representative on December 21, 2023, at 11:30 am, confirmed the appliances were being powered by a multi-outlet power tap.
Plan of Correction:1. Power Strip was removed from the employee break room.
2. Staff reminded at Safety Huddle that power strips are not to be used in the employee break room. Environment of Care Rounds will be completed five days a week for 1 month with focus on power strip usage in the employee break room. Results of environmental rounds will be compiled and shared with EVS provider as action items. Leadership will follow up with EVS on action items until 100% competed. Results from the environmental rounds will be shared with front line staff at staff meetings and safety huddles.
|