Pennsylvania Department of Health
PAM SPECIALTY HOSPITAL OF WILKES-BARRE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PAM SPECIALTY HOSPITAL OF WILKES-BARRE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: WILKES BARRE MAIN CAMPUS - Component: 67 - Tag: 0000

Facility ID # 141401
Component 67
Wilkes-Barre Main Campus

Based on a Relicensure Survey completed on September 23, 2020, PAM Specialty Hospital of Wilkes-Barre was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a nine story, Type II (222), fire-resistive structure that is fully sprinklered.

PAM Specialty Hospital of Wilkes-Barre is located on a portion of the seventh floor of Wilkes-Barre General Hospital, ID #234501-01.

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: WILKES BARRE MAIN CAMPUS - Component: 67 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler systems, affecting one of nine floors.

Findings include:

1. Observation on September 23, 2020, at 10:10 a.m., revealed the sprinkler gauges located in the "A" stair tower lacked the required five-year replacement or recalibration.

Exit interview with facility representative #1 on September 23, 2020, at 11:30 a.m., confirmed the gauges were dated 2014.

Plan of Correction - To be completed: 10/08/2020

The Director of Facilities had the sprinkler company change the outdated gauge on 10/5/2020.

It was determined that there was no policy changes needed at this time. The Director of Facilities educated the engineering staff and the sprinkler company on sprinkler gauge replacement of every 5 years in a healthcare setting.

To ensure continued compliance, the Facilities Director will complete ongoing monitoring of sprinkler gauges monthly to ensure they're in compliance of the 5 year changes. During the next round of changes, the Facilities Director will have the sprinkler company change out all the gauges so that they are all to be changed during the same month every 5th year.

The Facilities Director will document the monthly rounds on the sprinkler gauge inspections and report this information at a minimum of quarterly to the EOC Committee, and the Post Acute Medical Administration team.

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: WILKES BARRE MAIN CAMPUS - Component: 67 - Tag: 0914

Based on document review and interview, the facility failed to maintain electrical receptacles, affecting the entire facility.

Findings include:

1. Review of documentation on September 23, 2020, at 9:20 a.m., revealed the facility lacked records for a required annual electrical receptacle inspection.

Exit interview with facility representative #1 on September 23, 2020, at 11:30 a.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 10/08/2020

The electrical receptacle inspections were completed by the WBGH maintenance staff on 10/7/2020.

The Director of Facilities re-educated staff on policy EC.02.06.1.a – Patient Room Inspections, line item #6 "Check grounding, polarity and tension of electrical receptacles." The hospital requires this policy to be performed once per year in all patient rooms.

Continued monitoring by the Facilities Director will be implemented moving forward with tracer activities on Patient Room Inspection forms. The data collected will consist of checking to make sure all patient room receptacle inspections have been done in the last year.

This Facilities Director will report this information at a minimum of quarterly to the EOC Committee, and the Post Acute Medical Administration team.

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: WILKES BARRE MAIN CAMPUS - Component: 67 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain medical gas storage in one instance, affecting one of nine floors.

Findings include:

1. Observation on September 23, 2020, at 9:50 a.m., revealed an "E" sized oxygen cylinder stored within the ground floor "A" stair tower.

Exit interview with facility representative #1 on September 23, 2020, at 11:30 a.m., confirmed the oxygen cylinder being stored in the stair tower.

Plan of Correction - To be completed: 10/08/2020

The Director of Facilities removed the "E" sized oxygen cylinder from the stairwell immediately upon finding on 9/23/2020.

The Director of Facilities also re-educated all staff in the building via email on policy EC.02.05.09.6 – Compressed Gas Cylinder Management Policy.

This will also be monitored moving forward with policy EC.04.01.01 – Environmental Tours that are performed twice annually in all patient care areas and once annually in all ancillary departments in the facility.

The Facilities Director will report the data collected from the Environmental Tour Rounds at a minimum of quarterly to the EOC Committee, and the Post Acute Medical Administration team.

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