Nursing Investigation Results -

Pennsylvania Department of Health
PENN HIGHLANDS ELK
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PENN HIGHLANDS ELK
Inspection Results For:
There are 32 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.


PENN HIGHLANDS ELK - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID # 010901
Component 03
1984/2002 Building

Based on a Relicensure Survey completed on December 3-4, 2019, it was determined that Penn Highlands Elk, was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a three-story, Type I (322), fire resistive building, with a mechanical penthouse and a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Construction Type and Height:

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:
Name: BUILDING 03 - Component: 03 - Tag: 0161

Based on observation and inteview, the facility failed to maintain building construction on one of five building levels.

Findings include:

1. Observation on December 3, 2019, at 8:50 a.m., revealed a one-foot section of fire protective coating was removed from a structural steel beam, at the second floor link fire barrier wall, between the 1958 and the 2012 buildings.

Interview with the maintenance director and facility director on December 3, 2019, at 8:50 a.m., confirmed the above structural steel beam was missing fire protective coating.

Plan of Correction - To be completed: 01/31/2020

Fire coating will be purchased and applied to the affected area. This will be completed by January 31, 2020.

Maintenance will ascertain that when any work is completed on the fire barrier walls, the fire protective coating will be checked.

NFPA 101 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0211

Based on observation and inteview, the facility failed to maintain exit access, to be maintained free of all obstructions to full use in case of emergency, on two of five building levels.

Findings include:

1. Observation on December 3, 2019, between 9:20 a.m. and 10:45 a.m., revealed the following obstructions to exit access:

a. (9:20 a.m.) Second floor corridor, outside of patient room #13, had a holiday tree on top of a furniture stand blocking the corridor width;
b. (10:45 a.m.) First floor SPU (single door side), had a transport chair and wheelchair preventing the exit door of the suite from opening.

Interview with the maintenance director and facility director on December 3, 2019, at 10:45 a.m., confirmed the above exit access was obstructed.

Plan of Correction - To be completed: 12/05/2019

Tree and stand were removed on December 5, 2019.

(A) Staff has been instructed on keeping the corridors clear of obstructions and will audit the corridors on a monthly basis to prevent this in the future.
(B) The Chairs were relocated in SPU to were they would not block any corridor or Door openings and audits will be done on monthly basis in all areas of thy building starting December 16,2019

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0363

Based on observation and inteview, the facility failed to maintain corridor doors at four of over fifty corridor doors.

Findings include:

1. Observation on December 3, 2019, between 9:25 a.m. and 9:35 a.m., revealed the following second floor corridor doors lacked positive latching, due to linen carts placed between the sink and door opening:
a. (9:25 a.m.) 7;
b. (9:30 a.m.) 5;
c. (9: 33 a.m.) 3;
d. (9:35 a.m.) 21.

Interview with the maintenance director and facility director on December 3, 2019, at 9:35 a.m., confirmed the above corridor doors were obstructed, and would not close in the frame.

Plan of Correction - To be completed: 01/30/2020

On 12/5/19 all items (linen hampers) were removed from doorways. Talked and showed staff that what they did was wrong and explained why. By January 20, 2020 a new in-service will be done with staff of the Med Surg floor as new nurses and aides will be starting their employment. Completion date will be by 1-30-2020.

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:

Gas and Vacuum Piped Systems - Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0908

Based on document review and interview, it was determined the facility failed to remain in accordance with gas and vacuum piped system maintenance and testing regulations for one of one medical gas system.

Findings Include:

1. Document review on December 4, 2019, at 10:15 a.m., revealed there was no documentation to confirm the below inspection deficiences for the medical gas and vacuum piped system (testing completed on October 2-3, 2019) were corrected:

a. (10:15 a.m.) Area alarms;
b. (10:15 a.m.) Zone shutoff valves;
c. (10:15 a.m.) Outlets/inlets;
d. (10:15 a.m.) Gas/piping purity;
e. (10:15 a.m.) Central supply systems.

The facility lacked documentation that the above deficiencies on the medical gas testing report were corrected.

Interview with maintenance director and facility director on December 4, 2019, at 10:15 a.m., confirmed the above medical gas and vacuum system inspection deficiencies, and the lack of documentation that the deficiencies were corrected.

Plan of Correction - To be completed: 01/31/2020

Outside Contractor has submitted a quote for these deficiencies and a purchase order has been sent. All repairs will be done by January 31, 2020.

We had our gas and vacuum inspection done on October 2, and 3, 2019 by an outside certified contractor. We received their report on October 11, 2019 at which time we contacted them for a quote to do the repairs. We received the quote and authorized the repairs on October 21, 2019, at which time they had to order the parts needed for the repairs and schedule these repairs. We received a letter (email) from our contractor on December 12, 2019 stating all parts are in and they will be on-site on December 17, 2019 to complete all deficiencies. Moving forward we will continue to contact our contractor to keep our timeline from inspection to repairs up to date and done as quickly as possible.

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Information an:

Gas and Vacuum Piped Systems - Information and Warning Signs
Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency.
5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0909

Based on observation and inteview, the facility failed to maintain piped-in medical gas in one of over twenty five patient rooms.

Findings include:

1. Observation on December 3, 2019, at 11:30 a.m., revealed the medical gas piping, above the ceiling tile, at the ground floor stress room #1, across from patient room #4 Cardiology Exam, lacked proper labeling in accordance with regulations.

Interview with the maintenance director and facility director on December 3, 2019, at 11:30 a.m., confirmed the above medical gas piping was not labeled in accordance with regulations.

Plan of Correction - To be completed: 12/09/2019

The Maintenance Director applied the required labels in this location. Completed 12-9-19. Maintenance will continue to do spot audits to prevent this from happening in the future.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

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:
Name: BUILDING 03 - Component: 03 - Tag: 0914

Based on document review, observation and inteview, the facility failed to maintain line isolation monitors at two of two systems.

Findings include:

1. Document review on December 3, 2019, at 10:25 a.m., revealed the facility lacked documentation that the Operating Room suite line isolation monitors meet required testing.

Interview with the maintenance director and facility director on December 3, 2019, at 10:25 a.m., confirmed the above line isolation monitor testing documentation was not available at the time of the survey.

2. Observation on December 3, 2019, at 10:30 a.m., revealed the "Microlimb" line isolation monitor panel audible alarm and visual lamps were not functioning.

Interview with the maintenance director and facility director on December 3, 2019, at 10:25 a.m., confirmed the above line isolation monitor panel audible and visual indicators were not functioning.

Plan of Correction - To be completed: 02/15/2020

The outside contractor has been contacted and is being scheduled to come, test and repair any faults in the line of the isolation monitors. To be completed by 2-15-2020.

On December 9, 2019, an outside service company was contacted to get a quote for service to these line isolation monitors. On December 10, 2019, we authorized the service company to review the issues with the line isolation monitors and do any needed repairs and they are scheduled to be on-site on December 19, 2019. The OR staff has been in-serviced on the importance of these monitors and will do a monthly audit to see that we remain in compliance.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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:
Name: BUILDING 03 - Component: 03 - Tag: 0918

Based on observation and interview, it was determined the facility failed to maintain all emergency generators that service this building, in accordance with essential electric system requirements.

Findings Include:

1. Observation on December 4, 2019, at 9:50 a.m., revealed the facility failed to install a manual emergency stop station to the generator outside the room that houses the essential equipment (or elsewhere on the premises where the prime mover is located outside the building).

Interview with maintenance director and facility director on December 4, 2019, at 9:50 a.m., confirmed the above generator deficiency.

Plan of Correction - To be completed: 01/15/2020

Elco Electric Company has a purchase order (PO 5000008597), dated 11/25/19. They will be on site and have all emergency E Stops installed and tested by 1/15/2020.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

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:
Name: BUILDING 03 - Component: 03 - Tag: 0920

Based on observation and inteview, the facility failed to maintain electrical power cords in two of over fifty rooms.

Findings include:

1. Observation on December 4, 2019, between 9:10 a.m. and 9:15 a.m., revealed the following surge protector deficiencies within the ground floor Emergency department suite:

a. (9:10 a.m.) Breakroom had a surge protector suspended off the floor, hanging by the television cord;
b. (9:15 a.m.) Storage room surge protector was permanently mounted to the wall, with zip ties and screws.

Interview with the maintenance director and facility director on December 4, 2019, at 9:15 a.m., confirmed the above surge protector deficiencies.

Plan of Correction - To be completed: 12/05/2019

The surge protector has been mounted to the wall in the break room, and the permanent mounts on the one in the storage room had been removed on 12/5/19. Staff will be in-serviced on the proper installation of surge protectors.

Initial comments:Name: MRI - Component: 05 - Tag: 0000

Facility ID # 010901
Component 05
MRI Building

Based on a Relicensure Survey completed on December 3-4, 2019, it was determined that Penn Highlands Elk, was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Observations:
Name: MRI - Component: 05 - Tag: 0918

Based on observation and interview, it was determined the facility failed to maintain all emergency generators that service this building, in accordance with essential electric system requirements.

Findings Include:

1. Observation on December 4, 2019, at 9:50 a.m., revealed the facility failed to install a manual emergency stop station to the generator outside the room that houses the essential equipment (or elsewhere on the premises where the prime mover is located outside the building).

Interview with maintenance director and facility director on December 4, 2019, at 9:50 a.m., confirmed the above generator deficiency.

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