Nursing Investigation Results -

Pennsylvania Department of Health
INGLIS HOUSE
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
INGLIS HOUSE
Inspection Results For:

There are  45 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.
INGLIS HOUSE - 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 August 21-22, 2019, at Inglis House, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0000


Facility ID# 090202
Building 01
Main and Therapy Buildings

Based on a Medicare/Medicaid Recertification Survey conducted on August 21-22, 2019, it was determined that Inglis House - Main and Therapy Buildings were not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a five story, Type II (222), fire resistive construction, with a basement, which is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stair towers with the required fire resistive rating, and free of items not serving the stair tower, affecting six of six stair towers within the facility.

Findings Include:

1. Observation on August 21, 2019, between 10:00 am 2:15 pm, revealed wet floor signs were stored in the stair towers, throughout the facility.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed wet floor signs in the stair towers.


2. Observation on August 21, 2019, at 11:00 a.m., revealed the 1st floor south wing stair tower access door failed to positively latch into the frame when tested.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the door failed to positively latch.












 Plan of Correction - To be completed: 10/21/2019

1.
In the stair towers throughout the building, the wet floor signs were removed at the time of the inspection. The Environmental Services Department will be in-serviced on the Life safety Code and will be specifically educated about not leaving "Wet Floor" signs in stair towers. As a systematic change to prevent this condition, the weekly Stair Tower Preventative Maintenance Task, which is generated by the maintenance data base work order system will include instructions to report and remove Wet Floor signs from stair towers. Also the Engineering Service Managers will add this check to the weekly neighborhood rounds checklist to check stair towers for this condition. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.

2.
At the 1st Floor South Wing stair tower access, the door which was not latching was adjusted to latch properly at the time of inspection. As a systematic change to prevent this from happening again, the Maintenance Data Base weekly task to inspect fire towers will include an additional task instruction to verify for proper latching on all stair tower doors and checkoff "ok" or report to Engineering Office if a repair is needed. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.


The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Aisle, Corridor, or Ramp Width:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0232

Based on observation, document review and interview, it was determined the facility failed to maintain the minimum width of access corridors, affecting 2 of six levels within the facility.

Findings include:

1. Observation made and documentation reviewed on August 21, 2019, between 8:30 a.m. and 2:30 p.m., revealed the exit access corridors were less than four feet in width on the Third Floor (North Wing), Second Floor (North Wing), and the Second Floor (South Wing).

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the exit access corridor widths were less than the minimum requirement.








 Plan of Correction - To be completed: 10/21/2019

Inglis House is requesting the Pa Division of Life Safety to update the F.S.E.S. for this facility

The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Number of Exits - Corridors:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4




Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0252

Based on observation, document review and interview, it was determined the facility failed to ensure there were two remote exits from each floor, affecting 2 of nine smoke compartments within the component.

Findings include:

1. Observation made and documentation reviewed on August 21, 2019, between 8:30 a.m. and 2:30 p.m., revealed the Main Building (Fourth Floor - South Wing), lacked two remote exits.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the lack of two remote exits.







 Plan of Correction - To be completed: 10/21/2019

Inglis House is requesting the Pa Division of Life Safety to update the F.S.E.S. for this facility

The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0311

Based on observation, document review and interview, it was determined the facility failed to ensure vertical openings between floors were enclosed with the required fire resistance rating, affecting 5 of six levels within the facility.

Findings include:

1. Observation made and documentation reviewed on August 21, 2019, between 8:30 a.m. 2:30 p.m., revealed there were insulated pipes penetrating the floor slab at resident bathroom sink units. The insulation on the pipes continues through the floor slab. The pipes were maintained smoke tight at the ceiling/floor slab.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the penetrations through the floor.


2. Observation on August 21, 2019, at 9:20 am, revealed in North Wing attic, there was an opening approximately 8x12" inches in the floor/ceiling assembly, between the attic and the 4th floor.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the penetration.









 Plan of Correction - To be completed: 10/21/2019

1. Inglis House is requesting the Pa Division of Life Safety to update the F.S.E.S. for this facility



2.In the North Wing attic the 8X12 opening in the floor/ceiling assembly between the attic and 4th floor will be patched with 5/8 gypsum per 3M system HW-D-0488. As a systematic change a new preventative maintenance task will be implemented to check the attic for openings to the floor below and repair as needed. The preventative maintenance task will be automatically generated annually from the maintenance data base work order system and be performed by a member of the Engineering Services Maintenance Department. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.

The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to ensure doors to hazardous areas were self-closing and remained closed within the door frame, in three instances, affecting one of nine smoke compartments within the component.

Findings include:

1. Observation made on August 21, 2019, at 9:45 a.m., revealed the ground floor north wing elevator mechanical room H door, failed to close completely and positively latch into the door frame.

Interview at the exit conference with Administrator and Director of Maintenance on August 19, 2019, at 2:30 pm, confirmed the door failed to latch.



2. Observation made on August 21, 2019, at 9:55 a.m., revealed the ground floor kitchen dry storage room double doors failed to close completely and positively latch into their corresponding door frame assembly.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the doors failed to close and positively latch.



3. Observation made on August 21, 2019, at 10:35 a.m., revealed the ground floor south wing chapel office was utilized as a storage room. The corridor door lacked self-closing hardware.

Interview at the exit conference with Administrator and Director of Maintenance on August 19, 2019, at 2:30 pm, confirmed the door lacked a self-closing device.









 Plan of Correction - To be completed: 10/21/2019

1. At the Gound Floor North Wing Elevator Mechanical Room, the door was adjusted at the time of the survey to positively latch into the door frame. As a systematic change, a new preventative maintenance task will be implemented to check all 10 Inglis House mechanical room doors each month for proper closing and latching. The preventative maintenance task will be automatically generated each month from the maintenance data base work order system and be performed by a member of the Engineering Services Maintenance Department. The PM Task will include instructions and check off for proper latching.



2. At the Kitchen Dry Storage Room the double doors were adjusted at the time of the survey to positively latch. As a systematic change a specific task check off will be added to the Weekly Kitchen General Inspection which will instruct the maintenance person performing this PM Task. to check this door for proper closing and latching. Repair or report back to Engineering Manager. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.




3. At the Ground Floor South Wing Chapel Office, an automatic door closer was installed on this door. As a systematic change, a new preventative maintenance task will be implemented to annually check all unoccupied office space in the facility for improper storage and correct any improper storage by installing an auto closer or removing the storage. The task will be generated automatically from the MP2 maintenance data base work order system. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.



The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Smoke Detection:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1.
19.3.4.5.2
Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0347

Based on observation and interview, it was determined the facility failed to maintain smoke detectors within a in a smoke resistive ceiling assembly, affecting one of nine smoke compartments within this component.

Findings include:

1. Observation on August 21, 2019, at 9:50 am, revealed on the 4th floor, north wing, next to the computer lab, there was a hole in the ceiling tile next to a smoke detector.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm confirmed the hole in the ceiling.













 Plan of Correction - To be completed: 10/21/2019

At the 4th Floor North next to the Computer Lab, the broken ceiling tile next to the smoke detector has been replaced. As a systematic change a new monthly preventative maintenance task for the 4th floor will be implemented to check conditions including ceiling tiles and repair as needed. The task will be generated automatically monthly from the MP2 maintenance data base work order system. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.

The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. 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: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors free from impediments to closing and maintaining positive latching, affecting three of nine smoke compartments within this component.

Findings include:

1. Observation made on August 21, 2019, between 10:50 am and 1:30 pm, revealed the following corridor doors failed to latch into their frames:

a. 10:50 am, 4th floor, south wing, storage room next to resident library;
b. 1:30 pm, 3rd floor, north wing, resident room 331.
Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the doors failed to latch.

2. Observation made on August 21, 2019, at 2:00 p.m., revealed the 2nd floor south wing, room 227 corridor door was tied open with string onto a rack behind the door.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the door was impeded from closing.
















 Plan of Correction - To be completed: 10/21/2019

1. A. At the 4th floor South Wing storage room next to the library, the latch was adjusted to fully latch into the frame. As a systematic change an annual task will be generated automatically monthly from the MP2 maintenance data base work order system to check all doors on the 4th floor for proper operation which will include fully latching into the frame. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.



B. At the 3rd Floor South Wing Room 331, the latch was adjusted to fully latch into the frame. In addition to the Semi Annual Door Check Task , which is generated automatically from the MP2 maintenance data base work order system for that for all doors on that floor, The Engineering Managers will spot check doors each week while performing neighborhood rounds and document findings on the Rounding the Rounding Log Sheet. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.



2. At the 2nd Floor South Room 227 the string used to hold the door open was removed. As a systematic change to prevent staff and residents from tying doors open with strings, a task instruction will be added to the Room Inspection Preventative Maintenance Task to check for and remove any device that can be used to hold the door open and prevent it from being closed. The Room Inspection Task is performed every 20 weeks and is automatically generated by the MP2 maintenance data base work order system. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.


The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain the fire protection rating for laundry chutes, affecting six of six levels within the facility.

Findings include:

1. Observation on August 21, 2019, between 11:00 am and 2:15 pm, revealed the laundry chute doors throughout the facility had closing devices that were not fire-rated.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm confirmed the closers were not fire-rated.


2. Observation on August 21, 2019, between 11:00 am, and 2:15 pm, revealed the laundry chute doors throughout the facility had unsealed penetrations where self-closing devices had been replaced.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm confirmed the unsealed penetrations of the laundry chute doors.









 Plan of Correction - To be completed: 10/21/2019

1. The Laundry Chute doors throughout the facility with non-fire rated closers will be upgraded and changed to fire rated closers. As a systematic change to prevent the condition of non-fire rated closers to be used, the Weekly Preventative Maintenance Task generated automatically from the MP2 maintenance data base work order system will include a new task instruction to check, verify and document that the closer is labeled as fire rated. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.



2. The Laundry Chute doors throughout the facility that have unsealed penetrations where self-closing devices had been replaced will have the penetrations sealed by installing steel screws into each penetration. As a systematic change, a task instruction will be added to the Weekly Laundry Chute Inspection Preventative Maintenance Task to check for penetrations in the door and seal with steel screws. The Laundry Chute Inspection Task is performed every week and is automatically generated by the MP2 maintenance data base work order system. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.


The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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:
Name: MAIN BUILDING 01 & THERAPY BUILDING - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to protect electrical wiring, affecting two of nine smoke compartments within the facility.

Findings include:

1. Observation on August 21, 2019, at 2:10 pm, revealed on the 2nd floor North, above the suspended ceiling by elevator G, there was cable with exposed inner wiring.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the exposed wiring.


2. Observation on August 21, 2019, at 10:12 a.m., revealed within the ground floor Main Building engineering shop, there were two open electrical junction boxes with expose inner wiring.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the missing protective covers.


~Refer to 2011 edition of NFPA 70-314.28.





 Plan of Correction - To be completed: 10/21/2019

1. At the 2nd Floor North above the suspended ceiling by Elevator G, the exposed cable has been connected into a metal electrical junction box mounted to the wall. As a systematic change a task instruction will be added to the Penetration Preventative Maintenance Task to check for exposed wires and direct exposed wires into a mounted junction box. The Penetration Preventative Maintenance Task is generated automatically from the MP2 maintenance data base work order system will include this new task instruction. This preventative maintenance task check every section of the building every 25 weeks. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.






2. At the Ground Floor Engineering Shop the 2 open electrical junction boxes will be sealed with a metal cover. . As a systematic change a task instruction will be added to the Penetration Preventative Maintenance Task to check for exposed wires and direct exposed wires into a mounted junction box. The Penetration Preventative Maintenance Task is generated automatically from the MP2 maintenance data base work order system will include this new task instruction and a new specific location being the Engineering Shop. This preventative maintenance task checks every section of the building every 25 weeks.



The Engineering Director or designee will monitor this plan.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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 01 & THERAPY BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prevent the unauthorized use of electrical devices, affecting two of nine smoke compartments within this component.

Findings include:

1. Observation made on August 21, 2019, at 9:35 am, revealed at the 4th floor north wing, educational office, there was a microwave plugged into a surge protector.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the improper use of surge protectors.


2. Observation made on August 21, 2019, at 10:35 a.m., revealed within the ground floor south wing prayer and meditation room, there was a heavy duty orange extension cord with a television set plugged into into it.

Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the improper use of electrical device.










 Plan of Correction - To be completed: 10/19/2019

1. At the 4th Floor North Wing Educational Office the power strip was removed. As a systematic change the Bi-Annual Power Strip Inspection will have added to check every office in addition to every room in the building. The Bi-Annual Power Strip Inspection Preventative Maintenance Task is generated automatically from the MP2 maintenance data base work order system. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.



2. At the Ground Floor South Wing prayer and meditation room the heavy duty orange extension cord has been removed. As a systematic change the Bi-Annual Power Strip Inspection, which is a task that inspects the entire facility will have and a task instruction added to check and remove any extension cord. The Bi- Annual Power Strip Inspection Preventative Maintenance Task is generated automatically from the MP2 maintenance data base work order system. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port