Pennsylvania Department of Health
 SHARON REGIONAL HEALTH SYSTEM
Building Inspection Results

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SHARON REGIONAL HEALTH SYSTEM
Inspection Results For:

There are  57 surveys for this facility. Please select a date to view the survey results.

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SHARON REGIONAL HEALTH SYSTEM - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


This report is the result of an unannounced onsite Revisit survey completed on May 23, 2024, following a previous Complaint survey completed on March 14, 2024, at Sharon Regional Health System. It was determined that the facility was not in substantial compliance with the Emergency Preparedness regulations for Hospitals at 482.15.










 Plan of Correction:


403.748, 416.54, 418.113, 441.184, 482.15, 483.475, 483.73, 484.102, 485.542, 485.625, 485.68, 485.727, 485.920, 486.360, 491.12 CONDITION Establishment of the Emergency Program (EP):Not Assigned
§403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12

The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements:

* (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.)

*[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

*[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:
Observations:
Name: - Component: -- - Tag: 0001

Based on document review and interview, the facility failed to develop and maintain a comprehensive emergency preparedness program utilizing an all-hazards approach for the entire facility. Based on the seriousness of the non-compliance, the facility failed to substantially comply with this Condition.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 1:46 p.m., it was determined the facility failed to maintain a site-specific emergency power program based on the site risk assessment.

Interview with the regional director of facilities and emergency preparedness coordinator on May 23, 2024, at 1:46 p.m., confirmed the facility failed to complete the above deficiency at the time of the survey.













 Plan of Correction:

No approved Plan of Correction is on file.
482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:Not Assigned
§482.15(e) Condition for Participation:
(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e), §485.542(e)
(e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1)
Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2)
Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009..
Observations:
Name: - Component: -- - Tag: 0041

Based on document review and interview it was determined that the facility failed to develop an Emergency Preparedness Plan to include emergency and standby power, in one of one plan.

Findings include:

Document review during the revisit survey conducted on May 23, 2024, at 12:42 p.m., revealed the facility failed to maintain a site-specific emergency power program based on the site risk assessment due to following unresolved deficiencies:
A. (12:28 p.m.) The facility was informed by their emergency generator vendor that the generator batteries need attention and the facility failed to provide documented evidence that this was corrected;
B. (12:30 p.m.) The facility failed to provide documented evidence that generators number five and eight had a four-hour load test completed;
C. (12:36 p.m.) The annual fuel sample results were not available to verify that the fuel quality met regulatory requirements;
D. (12:42 p.m.) Generator #1 annunciator panel lamp/ sound buttons were not corrected;

Interview with the regional director of facilities and emergency preparedness coordinator on May 23, 2024, at 12:42 p.m., confirmed the facility failed to complete the above deficiency at the time of the survey.












 Plan of Correction:

No approved Plan of Correction is on file.
Initial comments:Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0000


Facility ID # 196601
Component 01
B/C Building

This report is the result of an unannounced onsite Revisit survey completed on May 23, 2024, following a previous complaint survey completed on March 14, 2024, at Sharon Regional Health System. It was determined that the facility was not in substantial compliance with the requirements of the Life Safety Code, 2012 Edition. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 482.41(b).

This is a five-story Type II (000), Unprotected noncombustible construction building that is fully sprinklered.



















 Plan of Correction:


NFPA 101 STANDARD Cooking Facilities:Not Assigned
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0324

Based on document review and interview, it was determined that the facility failed to meet requirements for one of three cooking facilities.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 1:51 p.m., revealed that the facility failed to correct the semi-annual suppression test/ maintenance and the semi-annual hood/ duct cleaning for the "bake shop". The facility provided two quotes from a vendor with pre-paid terms and communicated that they were sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this at the time of the revisit survey.

Interview with the regional director of facilities on May 23, 2024, at 1:51 p.m., confirmed the facility lacked documentation to indicate the above repairs were completed or that the quotes were approved by the corporate leadership at the time of the revisit survey.
























 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Not Assigned
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: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0353

Based on document review and interview, it was determined that the facility failed to remain in compliance with sprinkler system requirements, affecting the entire component.
Findings include:
Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:36 a.m., revealed the facility failed to provide documentation to indicate that the sprinkler head that was lacking in the dumbwaiter shaft was corrected. The facility provided a quote from a vendor to correct the sprinkler deficiency. However, through interview it was communicated that this item would require additional investigation and potential costs due to the temperature environment within the shaft. There was a concern that this area would be too cold in the winter months and they would need to address possible freezing conditions.

Interview with the regional director of facilities on May 23, 2024, at 11:36 a.m., confirmed the facility lacked documentation to indicate the above sprinkler deficiency was corrected at the time of the survey.












 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:Not Assigned
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: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0372

Based on document review, observation and interview, the facility failed to meet requirements for smoke resistant barriers, to resist the passage of smoke, affecting the entire building component.

Findings include:

1. Observation and interview, during an onsite revisit survey conducted on May 23, 2024, between 11:19 a.m. and 12:12 p.m., revealed that the facility lacked documentation to indicate that all the damaged ceiling tiles identified throughout the facility were replaced. Through interview, it was communicated that the facility purchased and installed four pallets of ceiling tile and continue to address the ceiling tile deficiencies. Observation revealed there was significant amount of ceiling tiles replaced but there were areas that remain deficient and still needed corrected at the time of the revisit survey. The facility communicated that the maintenance staff will continue replacing damaged tiles to completion.

2. Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:49 a.m., revealed the facility lacked documentation to indicate that the deficiencies identified in the smoke/ fire damper report (completed 3/14/24 to 5/7/24) were corrected. Through interview, it was communicated that there was a plan to have a vendor conduct any of the remaining repairs. The facility provided an e-mail (dated 3/12/24) from the vendor, conveying that a technician will be onsite to conduct the repairs on June 4, 2024.

Interview with the regional director of facilities on May 23, 2024, at 12:12 p.m., confirmed the facility lacked documentation to indicate the above deficiencies were corrected at the time of the revisit survey.













 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:Not Assigned
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0761

Based on documentation review and interview, the facility failed to maintain fire and smoke rated door assemblies, affecting twenty-three out of over one hundred rated fire doors.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:54 a.m., revealed the facility lacked documentation to indicate that twenty-three deficiencies identified during the annual inspection (conducted May 23, 2023) were corrected. The facility provided an invoice from a vendor with pre-paid terms and communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this at the time of the revisit survey.

Interview with the regional director of facilities on May 23, 2024, at 11:54 a.m., confirmed the facility lacked documentation to indicate the above repairs were completed or that the quotes were approved by corporate leadership at the time of the revisit survey.










 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:Not Assigned
Gas and Vacuum Piped Systems - Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)
Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0908

Based on document review and interview, it was determined the facility failed to remain in compliance with annual medical gas system maintenance and testing regulation, affecting the entire facility.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 12:14 p.m., it was determined the facility failed to correct the gas and vacuum piped system deficiencies identified in the annual report completed on January 13, 2022. Furthermore, the facility provided an updated annual inspection of the medical gas piping, completed on April 4, 2024. The report indicated multiple deficiencies in the executive summary. These included master alarms, area alarms, zone shutoff valves, outlets/ Inlets, central supply systems, etc. The list below contains an outline of the deficiencies:
a)Area monitored labeling not present, incorrect or unclear;
b)Gauges defective;
c)Leakage detected;
d)Valve not locked, latched, or in secure area as required;
e)Defective/ missing parts;
f)Leak with connector in;
g)Leak with connector out;
h)Reduced flow/ no flow.
The facility provided an invoice from a vendor with pre-paid terms to repair the deficiencies identified in these reports. They communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this at the time of the revisit survey.

Interview with the regional director of facilities on May 23, 2024, at 12:14 p.m., confirmed the facility lacked documentation to indicate the above repairs were completed or that the quotes were approved by corporate at the time of the revisit survey.











 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Not Assigned
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: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance for six of six emergency generators.

Findings include:

1. Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 12:42 p.m., it was determined the facility failed to correct the annunciator panel for generator #1. The facility provided an e-mail from a vendor indicating that a required relay that is necessary to correct the deficiency was not immediately available. The vendor also noted they were in the process of obtaining one and will make the repairs when the part is received.

Interview with the regional director of facilities on May 23, 2024, at 12:42 p.m., confirmed the facility failed to correct the above deficiency at the time of the revisit survey.

2. Based on document review and interview, during an onsite revisit survey conducted on May 23, 2024, between 12:28 p.m. and 12:40 p.m., revealed that the facility failed to correct the following generator deficiencies:
A. (12:28 p.m.) the facility provided an invoice from a vendor with pre-paid terms to replace the generator batteries. They communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this;
B. (1230 p.m.) the facility provided quotes to complete the four-hour load test for generator #5 and #8 with pre-paid terms. They communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this;
C. (12:36 p.m.) documentation was reviewed to indicate that fuel samples were taken on 5/16/24 but the results were not available to verify that the fuel quality met regulatory requirements.

Interview with the regional director of facilities on May 23, 2024, at 12:36 p.m., confirmed the facility failed to correct the above deficiencies at the time of the revisit survey.













 Plan of Correction:

No approved Plan of Correction is on file.
Initial comments:Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0000


Facility ID # 196601
Component 02
A Building

This report is the result of an unannounced onsite Revisit survey completed on May 23, 2024, following a previous complaint survey completed on March 14, 2024, at Sharon Regional Health System. It was determined that the facility was not in substantial compliance with the requirements of the Life Safety Code, 2012 Edition. 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 fully sprinklered.









 Plan of Correction:


NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:Not Assigned
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: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0372

Based on document review, observation and interview, the facility failed to meet requirements for smoke resistant barriers, to resist the passage of smoke, affecting the entire building component.

Findings include:

1. Observation and interview, during an onsite revisit survey conducted on May 23, 2024, between 11:19 a.m. and 12:12 p.m., revealed that the facility lacked documentation to indicate that all the damaged ceiling tiles identified throughout the facility were replaced. Through interview, it was communicated that the facility purchased and installed four pallets of ceiling tile and continue to address the ceiling tile deficiencies. Observation revealed there was significant amount of ceiling tiles replaced but there were areas that remain deficient and still needed corrected at the time of the revisit survey. The facility communicated that the maintenance staff will continue replacing damaged tiles to completion.

2. Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:49 a.m., revealed the facility lacked documentation to indicate that the deficiencies identified in the smoke/ fire damper report (completed 3/14/24 to 5/7/24) were corrected. Through interview, it was communicated that there was a plan to have a vendor conduct any of the remaining repairs. The facility provided an e-mail (dated 3/12/24) from the vendor, conveying that a technician will be onsite to conduct the repairs on June 4, 2024.

Interview with the regional director of facilities on May 23, 2024, at 12:12 p.m., confirmed the facility lacked documentation to indicate the above deficiencies were corrected at the time of the revisit survey.







 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:Not Assigned
Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)
Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0761

Based on documentation review and interview, the facility failed to maintain fire and smoke rated door assemblies, affecting twenty-three out of over one hundred rated fire doors.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:54 a.m., revealed the facility lacked documentation to indicate that twenty-three deficiencies identified during the annual inspection (conducted May 23, 2023) were corrected. The facility provided an invoice from a vendor with pre-paid terms and communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this at the time of the revisit survey.

Interview with the regional director of facilities on May 23, 2024, at 11:54 a.m., confirmed the facility lacked documentation to indicate the above repairs were completed or that the quotes were approved by corporate leadership at the time of the revisit survey.







 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:Not Assigned
Gas and Vacuum Piped Systems - Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)
Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0908

Based on document review and interview, it was determined the facility failed to remain in compliance with annual medical gas system maintenance and testing regulation, affecting the entire facility.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 12:14 p.m., it was determined the facility failed to correct the gas and vacuum piped system deficiencies identified in the annual report completed on January 13, 2022. Furthermore, the facility provided an updated annual inspection of the medical gas piping, completed on April 4, 2024. The report indicated multiple deficiencies in the executive summary. These included master alarms, area alarms, zone shutoff valves, outlets/ Inlets, central supply systems, etc. The list below contains an outline of the deficiencies:
a)Area monitored labeling not present, incorrect or unclear;
b)Gauges defective;
c)Leakage detected;
d)Valve not locked, latched, or in secure area as required;
e)Defective/ missing parts;
f)Leak with connector in;
g)Leak with connector out;
h)Reduced flow/ no flow.
The facility provided an invoice from a vendor with pre-paid terms to repair the deficiencies identified in these reports. They communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this at the time of the revisit survey.

Interview with the regional director of facilities on May 23, 2024, at 12:14 p.m., confirmed the facility lacked documentation to indicate the above repairs were completed or that the quotes were approved by corporate at the time of the revisit survey.







 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Not Assigned
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: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance for six of six emergency generators.

Findings include:

1. Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 12:42 p.m., it was determined the facility failed to correct the annunciator panel for generator #1. The facility provided an e-mail from a vendor indicating that a required relay that is necessary to correct the deficiency was not immediately available. The vendor also noted they were in the process of obtaining one and will make the repairs when the part is received.

Interview with the regional director of facilities on May 23, 2024, at 12:42 p.m., confirmed the facility failed to correct the above deficiency at the time of the revisit survey.

2. Based on document review and interview, during an onsite revisit survey conducted on May 23, 2024, between 12:28 p.m. and 12:40 p.m., revealed that the facility failed to correct the following generator deficiencies:
A. (12:28 p.m.) the facility provided an invoice from a vendor with pre-paid terms to replace the generator batteries. They communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this;
B. (1230 p.m.) the facility provided quotes to complete the four-hour load test for generator #5 and #8 with pre-paid terms. They communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this;
C. (12:36 p.m.) documentation was reviewed to indicate that fuel samples were taken on 5/16/24 but the results were not available to verify that the fuel quality met regulatory requirements.

Interview with the regional director of facilities on May 23, 2024, at 12:36 p.m., confirmed the facility failed to correct the above deficiencies at the time of the revisit survey.













 Plan of Correction:

No approved Plan of Correction is on file.
Initial comments:Name: CANCER TREATMENT CENTER - Component: 10 - Tag: 0000


Facility ID # 196601
Component 10
Cancer Center - Linear Accelerator/Simulator Area

This report is the result of an unannounced onsite Revisit survey completed on May 23, 2024, following a previous complaint survey completed on March 14, 2024, at Sharon Regional Health System. It was determined that the facility was not in substantial compliance with the requirements of the Life Safety Code, 2012 Edition. 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 (111), protected, wood building, that is partially sprinklered.








 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:Not Assigned
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: CANCER TREATMENT CENTER - Component: 10 - Tag: 0345

Based on document review and interview, the facility failed to maintain fire alarm systems for one of one fire alarm system affecting the entire building.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:17 a.m., revealed that the facility failed to correct the following deficiencies:
A. Annual fire alarm inspection;
B. Semi-annual fire alarm visual inspection;
C. Smoke detector sensitivity testing.
Through interview, it was communicated that a vendor was going to be onsite to complete the above items on 6/4/24. There was no invoice, quote or other documented evidence to verify this at the time of the revisit survey.

Interview with the regional director of facilities on May 23, 2024, at 11:17 a.m., confirmed the facility failed to complete the above deficiencies at the time of the revisit survey.











 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Not Assigned
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: CANCER TREATMENT CENTER - Component: 10 - Tag: 0353

Based on document review and interview, it was determined that the facility failed to remain in compliance with sprinkler system regulations for one of one system.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 12:54 p.m., it was determined the facility failed to complete the five-year internal valve and pipe inspection. The facility provided a quote (dated 5/7/24) to complete the 5-year inspection. There were additional items noted on the quote to be repaired for all the facility components. It was communicated that this would be completed on 6/4/24.

Interview with the regional director of facilities on May 23, 2024, at 12:54 p.m., confirmed the facility failed to complete the above 5-year internal valve and pipe inspection at the time of the revisit survey.







 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:Not Assigned
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: CANCER TREATMENT CENTER - Component: 10 - Tag: 0372

Based on document review, observation and interview, the facility failed to meet requirements of a smoke resistant barriers, to resist the passage of smoke, affecting the entire building.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:49 a.m., revealed the facility failed to obtain the annual fire and smoke damper testing and exercising. The facility provided an e-mail (dated 3/12/24) from the vendor, conveying that a technician will be onsite conducting the testing and repairs on 6/4/24.

Interview with the regional director of facilities on March 12, 2024, at 11:49 a.m., confirmed the facility failed to correct the above deficiency at the time of the revisit survey.










 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Not Assigned
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: CANCER TREATMENT CENTER - Component: 10 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance for one of one emergency generator.

Findings include:

Based on document review and interview, during an onsite revisit survey conducted on May 23, 2024, between 12:28 p.m. and 12:36 p.m., revealed the facility failed to correct the following generator deficiencies:
A. (12:28 p.m.) the facility provided an invoice from a vendor with pre-paid terms to replace the generator batteries. They communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this;
B. (12:36 p.m.) documentation was reviewed to indicate that fuel samples were taken on 5/16/24 but the results were not available to verify that the fuel quality met regulatory requirements.

Interview with the regional director of facilities on May 23, 2024, at 12:36 p.m., confirmed the facility failed to correct the above deficiencies at the time of the revisit survey.










 Plan of Correction:

No approved Plan of Correction is on file.
Initial comments:Name: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0000


Facility ID # 196601
Component 11
Cancer Center - Exam/Rehab Area

This report is the result of an unannounced onsite Revisit survey completed on May 23, 2024, following a previous complaint survey completed on March 14, 2024, at Sharon Regional Health System. It was determined that the facility was not in substantial compliance with the requirements of the Life Safety Code, 2012 Edition. 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, non-combustible building, that is fully sprinklered.







 Plan of Correction:


NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:Not Assigned
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0345

Based on document review and interview, the facility failed to maintain fire alarm systems for one of one fire alarm system affecting the entire building.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:17 a.m., revealed that the facility failed to correct the following deficiencies:
A. Annual fire alarm inspection;
B. Semi-annual fire alarm visual inspection;
C. Smoke detector sensitivity testing.
Through interview, it was communicated that a vendor was going to be onsite to complete the above items on 6/4/24. There was no invoice, quote or other documented evidence to verify this at the time of the revisit survey.

Interview with the regional director of facilities on May 23, 2024, at 11:17 a.m., confirmed the facility failed to complete the above deficiencies at the time of the revisit survey.










 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Not Assigned
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: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0353

Based on document review and interview, it was determined that the facility failed to remain in compliance with sprinkler system regulations for one of one system.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 12:54 p.m., it was determined the facility failed to complete the five-year internal valve and pipe inspection. The facility provided a quote (dated 5/7/24) to complete the 5-year inspection. There were additional items noted on the quote to be repaired for all the facility components. It was communicated that this would be completed on 6/4/24.

Interview with the regional director of facilities on May 23, 2024, at 12:54 p.m., confirmed the facility failed to complete the above 5-year internal valve and pipe inspection at the time of the revisit survey.








 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:Not Assigned
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: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0372

Based on document review, observation and interview, the facility failed to meet requirements of a smoke resistant barriers, to resist the passage of smoke, affecting the entire building.

Findings include:

Document review and interview, during an onsite revisit survey conducted on May 23, 2024, at 11:49 a.m., revealed the facility failed to obtain the annual fire and smoke damper testing and exercising. The facility provided an e-mail (dated 3/12/24) from the vendor, conveying that a technician will be onsite conducting the testing and repairs on 6/4/24.

Interview with the regional director of facilities on March 12, 2024, at 11:49 a.m., confirmed the facility failed to correct the above deficiency at the time of the revisit survey.






 Plan of Correction:

No approved Plan of Correction is on file.
NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Not Assigned
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: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0918

Based on document review and interview, the facility failed to maintain essential electric system maintenance for one of one emergency generator.

Findings include:

Based on document review and interview, during an onsite revisit survey conducted on May 23, 2024, between 12:28 p.m. and 12:36 p.m., revealed the facility failed to correct the following generator deficiencies:
A. (12:28 p.m.) the facility provided an invoice from a vendor with pre-paid terms to replace the generator batteries. They communicated that it was sent to corporate leadership for approval. However, the facility failed to provide documented evidence to verify this;
B. (12:36 p.m.) documentation was reviewed to indicate that fuel samples were taken on 5/16/24 but the results were not available to verify that the fuel quality met regulatory requirements.

Interview with the regional director of facilities on May 23, 2024, at 12:36 p.m., confirmed the facility failed to correct the above deficiencies at the time of the revisit survey.








 Plan of Correction:

No approved Plan of Correction is on file.

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