Pennsylvania Department of Health
POTTSTOWN HOSPITAL
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 61 surveys for this facility. Please select a date to view the survey results.

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POTTSTOWN 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 March 15, 2018, at Pottstown 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 - Component: 01 - Tag: 0000

Facility ID# 163201
Component 01
Main Building

Based on a Revisit to an Unannounced Medicare Sample Validation Survey completed on March 14 -15, 2018, it was determined that Pottstown Hospital - Main Building 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 482.41(b).

This is a seven-story, Type II (000), unprotected non-combustible structure, with a basement and penthouse, which 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: MAIN BUILDING - Component: 01 - Tag: 0161

Based on observation, document review and interview, it was determined the facility failed to maintain building construction requirements, such as a minimum two-hour fire resistive rating of structural components throughout the building, affecting the entire component.

Findings include:

1. Interview, observation and document review on March 14, 2018, between 8:00 a.m. and 11:00 a.m., revealed the building is a seven story, Type II (000) unprotected noncombustible structure. This type of construction exceeds the maximum story height allowed.

Exit Interview with the Director, Facilities Services, on March 15, 2018, at 2:30 p.m., confirmed the building construction type and height.
**********************************

Based on an Onsite Revisit conducted on November 13, 2023, between 11:00 a.m. and 1:00 p.m., revealed the following:

Item 1 Not Completed. The building is a seven story, Type II (000) unprotected, non-combustible structure. This type of construction exceeds the maximum allowed for this story height.

Exit Interview with the Director of Facilities Management on November 13, 2023, at 1:00 p.m., confirmed the building construction type and height.

Plan of Correction - To be completed: 03/04/2024

1)Hire and consult a professional fire protection engineer. Extend time-limited waiver to July 5th, 2028, and complete continuous compliance items in updated FSES.
a. Pottstown Hospital has retained Koffel Associates to prepare an updated FSES using the TIA which is anticipated to demonstrate equivalency once completed.

b. Put into place an updated time-limited waiver. Per TIA 13-2 for NFPA 101A (2013 edition), lower mandatory values are permitted to be used in FSES's for existing hospitals where the phase-in period for the requirement for sprinklers in 19.4.2 of NFPA 101 has not yet elapsed. The referenced TIA is provided as an Attachment forwarded in email to the Department of Health. It is requested that Pottstown Hospital be permitted to utilize TIA 13-2 until the plan for improvement is completed, but no later than July 5, 2028. Continuous compliance items currently noted will be remedied within 60 days. Compliance items noted in the FSES analysis conclusion will be maintained at all times.

2) Pottstown Hospital will submit the appropriate documentation for review to PA DOH LSI and all other AHJs regarding any necessary permitted and inspected work. All necessary work will be submitted to PA DOH LSI for compliance inspection/validation.

A full FSES plan detailing the plan of correction and considerations has been emailed to Charlie Schlegel and Gwendolyn Hilliard of PA DOH LSI.

The Chief Executive Officer is ultimately responsible for all corrective actions and ongoing compliance associated with this element of performance.

Initial comments:Name: POTTSTOWN SCANNING AND TREATMENT CENTER - Component: 10 - Tag: 0000

Facility ID# 163201
Component 10
Pottstown Scanning and Treatment Center

Based on a Revisit to an Unannounced Medicare Sample Validation Survey completed on March 14 -15, 2018, it was determined that Pottstown Hospital - Pottstown Scanning and Treatment Center was in substantial 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 482.41(b).

This is a one-story, Type V (000), unprotected wood frame structure, which is fully sprinklered.

Plan of Correction:

Initial comments:Name: OUTPATIENT SERVICES - Component: 12 - Tag: 0000

Facility ID# 163201
Building 12
Outpatient Services

Based on a Revisit to an Unannounced Medicare Sample Validation Survey completed on March 14 - 15, 2018, it was determined that Pottstown Hospital - Outpatient Services was in substantial 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 482.41(b).

This is a two-story, Type II (222), fire resistive structure, with a penthouse, which is fully sprinklered.

Plan of Correction:

Initial comments:Name: BOYERTOWN OUTPATIENT REHAB & IMAGING - Component: 20 - Tag: 0000

Facility ID# 163201
Component 20
Boyertown Imaging

Based on a Revisit to an Unannounced Medicare Sample Validation Survey completed on March 14 -15, 2018, it was determined that Pottstown Hospital - Boyertown Imaging was in substantial 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 482.41(b).

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

Plan of Correction:

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