Pennsylvania Department of Health
INDEPENDENCE HEALTH SYSTEM BUTLER MEMORIAL HOSPITAL
Building Inspection Results

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INDEPENDENCE HEALTH SYSTEM BUTLER MEMORIAL HOSPITAL
Inspection Results For:

There are  115 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.
INDEPENDENCE HEALTH SYSTEM BUTLER MEMORIAL HOSPITAL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID # 023701
Component 01
Main Building

Based on a Revisit to a Relicensure Survey completed on February 7-8, 2024, it was determined that Butler Memorial 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 six-story, Type II (222), fire resistive building, with a basement, that is partially sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:State only Deficiency.
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: MAIN BUILDING - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to meet electrical system requirements for three of three building components.

Findings include:

Document review on February 7, 2024, at 9:33 a.m., revealed the last documented three-year, four-hour load test was completed November 2020.

Interview with the director of facilities on February 7, 2024, at 9:33 a.m., confirmed the last date of the test and scheduled a new load test for May 2024.


************************
Interview with the chief nursing officer during an Onsite Revisit Survey conducted on April 4, 2024, at 10:45 a.m., revealed the deficiency was not corrected, and the facility was in the process of ordering and scheduling the emergency generator four-hour full load test.




 Plan of Correction - To be completed: 05/06/2024

On 2/7/24 Cleveland Brothers was scheduled for April 29, 2024 to complete the 4-hour load test. PO generated. W/O #527054. Findings will be reported to the Safety Committee.
Initial comments:Name: NEW PATIENT TOWER BUILDING - Component: 02 - Tag: 0000


Facility ID # 023701
Component 02
Tower Building

Based on a Revisit to a Relicensure Survey completed on February 7-8, 2024, it was determined that Butler Memorial 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 seven-story, Type II (222), fire resistive building, with a penthouse, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:State only Deficiency.
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: NEW PATIENT TOWER BUILDING - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to meet electrical system requirements for three of three building components.

Findings include:

Document review on February 7, 2024, at 9:33 a.m., revealed the last documented three-year, four-hour load test was completed November 2020.

Interview with the director of facilities on February 7, 2024, at 9:33 a.m., confirmed the last test date and scheduled a new load test for May 2024.


************************
Interview with the chief nursing officer during an Onsite Revisit Survey conducted on April 4, 2024, at 10:45 a.m., revealed the deficiency was not corrected, and the facility was in the process of ordering and scheduling the emergency four-hour full load test.



 Plan of Correction - To be completed: 05/06/2024

On 2/7/24 Cleveland Brothers was scheduled for April 29, 2024 to complete the 4-hour load test. PO generated. W/O #527054. Findings will be reported to the Safety Committee.
Initial comments:Name: NORTH WING & X BLDG - Component: 03 - Tag: 0000


Facility ID # 023701
Component 03
North Wing & X Building

Based on a Revisit to a Relicensure Survey completed on February 7-8, 2024, it was determined that Butler Memorial 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 six-story, Type II (222), fire resistive building, that is partially sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:State only Deficiency.
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: NORTH WING & X BLDG - Component: 03 - Tag: 0918

Based on document review and interview, the facility failed to meet electrical system requirements for three of three building components.

Findings include:

Document review on February 7, 2024, at 9:33 a.m., revealed the last documented three-year, four-hour load test was completed November 2020.

Interview with the director of facilities on February 7, 2024, at 9:33 a.m., confirmed the last test date and scheduled a new load test for May 2024.

************************
Interview with the chief nursing officer during an Onsite Revisit Survey conducted on April 4, 2024, at 10:45 a.m., revealed the deficiency was not corrected, and the facility was in the process of ordering and scheduling the emergency generator four-hour full load test.



 Plan of Correction - To be completed: 05/06/2024

On 2/7/24 Cleveland Brothers was scheduled for April 29, 2024 to complete the 4-hour load test. PO generated. W/O #527054. Findings will be reported to the Safety Committee.

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