Pennsylvania Department of Health
EAGLEVILLE HOSPITAL
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 26 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.


EAGLEVILLE HOSPITAL - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Based on an Emergency Preparedness Survey completed on May 12, 2025, at Eagleville 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 03 (D'ARCLAY BUILDING) - Component: 34 - Tag: 0000

Facility ID# 051001
Component 34
Building 03
D'Arclay Building

Based on a Recertification Survey completed on May 12, 2025, it was determined that Eagleville Hospital was not in compliance with the requirements of the Life Safety Code for an existing Hospital health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 418.110 (d).

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

Plan of Correction:

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN - BUILDING 03 (D'ARCLAY BUILDING) - Component: 34 - Tag: 0355

Based on observation, interview, and document review, it was determined the facility failed to ensure fire alarm inspectors were certified, affecting the entire facility.

Findings include:

Document review on May 12, 2025, at 8:30 a.m., revealed the facility could not provide certification documentation for the inspector that performed the facility's annual portable fire extinguisher inspection in June 2024.

Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing documentation.

Plan of Correction - To be completed: 05/12/2025

The verification of certification was obtained on May 12, 2025 at 2:14 pm (approximately 15 minutes after the inspectors left the campus). EH will ensure that the certification for the inspector(s) will be maintained in the EOC files.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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:
Name: MAIN - BUILDING 03 (D'ARCLAY BUILDING) - Component: 34 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barrier walls, affecting one of two levels.

Findings include:

Observations on May 12, 2025, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 12:25 p.m., open penetrations above entry smoke door, on the first floor, Acute Psychology Unit;
b. 12:45 p.m., open penetration above entry smoke door labeled #34, on the second floor, D2 West.

Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the smoke wall penetrations.

Plan of Correction - To be completed: 07/11/2025

EH met with a vendor to discuss repairing the penetrations identified during the onsite visit, and inspect for and repair existing penetrations and any other identified penetration areas. Penetration fire-stop system will be used to seal the penetration's through the rated partitions.

EH will immediately reinstate the in-house form titled "above ceiling work permit" that any department needing to run lines or penetrate fire walls will be required to complete. Along with the form, they will be required to take before work and after work pictures that will be maintained in a file. Any penetrations will be inspected and repaired according to code. System numbers will be kept on file for future reference.

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, readily identifiable, and separate from normal power circuits. 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 03 (D'ARCLAY BUILDING) - Component: 34 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain and test the generator, affecting the entire facility.

Findings include:

Document review on May 12, 2025, at 8:30 a.m., revealed the facility could not produce documentation of the Annual Fuel Quality Test.

Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing fuel quality report.

Plan of Correction - To be completed: 07/11/2025

Fuel quality samples were taken on 6/4 and 6/5. They were sent to the lab.EH will maintain a file with the results once received. We will engage the contractor who inspects the generator to test these samples annually each June.

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: MAIN - BUILDING 03 (D'ARCLAY BUILDING) - Component: 34 - Tag: 0920

Based on observation and interview it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of two levels.

Findings include:

Observation on May 12, 2025, at 12:30 p.m., revealed a refrigerator plugged into a power strip, the first EVS Administration office.

Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the unauthorized electrical device.

Plan of Correction - To be completed: 07/06/2025

The safety officer and patient safety officer will send out a staff training notification addressing the proper use of UL rated power cords. Employees will sign an attestation of understanding. This will be completed by July 6, 2025.

Power strip identified during the on-site visit was removed.

Leadership will monitor for non-compliant use of power strips during EOC rounds. Any non-compliance will be addressed immediately and staff will be retrained.

Initial comments:Name: BUILDING 06 (NEW PATIENT CARE BUILDING) - Component: 89 - Tag: 0000

Facility ID# 051001
Component 89
Building 06
New Patient Care Building

Based on a Recertification Survey completed on May 12, 2025, it was determined that Eagleville Hospital was not in compliance with the requirements of the Life Safety Code for an existing Hospital health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 418.110 (d).

This is a two-story, Type II (111), protected noncombustible building, that is fully sprinklered

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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:
Name: BUILDING 06 (NEW PATIENT CARE BUILDING) - Component: 89 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of two levels.

Findings include:

Observation on May 12, 2025, at 11:50 a.m., revealed a sprinkler missing its escutcheon plate, Admissions Office next to supply closet.

Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing escutcheon.

Plan of Correction - To be completed: 05/29/2025

The identified missing escutcheon was replaced May 13, 2025.

The Environment of Care rounding checklist includes the following criteria for review: "Sprinkler heads are clean (dust free and corrosion free) escutcheon plates are present". EOC rounds are scheduled by the EOC director bi-weekly, the sprinkler head review is completed during these rounds. . Patient Safety, Patient Experience and Leadership perform regular rounding and will add this to the rounding inspections.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: BUILDING 06 (NEW PATIENT CARE BUILDING) - Component: 89 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of medical gas rooms, in sprinklered locations, affecting one of two levels.

Findings include:

Observation on May 12, 2025, at 11:20 a.m., revealed, on the first floor, in room 112 Oxygen Storage Room door lacked a self-closer.

Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the oxygen storage door deficiency.

Plan of Correction - To be completed: 05/23/2025

The self-closing apparatus was added to the door identified during the site visit. All doors were checked for appropriate closures

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