Pennsylvania Department of Health
SHARON REGIONAL HEALTH SYSTEM
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 56 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

Based on an Emergency Preparedness Survey completed on March 12-14, 2024, it was determined that Sharon Regional Health System, was not in compliance with the requirements of 42 CFR 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):

§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.

Document review on March 12 through March 13, 2024, at 1:37pm, revealed the following standards were cited and show a systemic nature of non-compliance with regards to Emergency Preparedness as follows:

482.15(d) Emergency Preparedness Training and Testing - the facility failed to maintain emergency preparedness guidelines (E0036)

482.15(d)(2) Hospital CAH and LTC Emergency Power - the facility failed to develop an Emergency Preparedness Plan that included the emergency and standby power (E0041).

Interview with the administrator and director of environmental services on March 13, 2024, at 1:37 p.m., confirmed the emergency preparedness plan did not include the above elements at the time of the survey.

Plan of Correction - To be completed: 05/17/2024

1. The Emergency Management Director and Administrator reviewed the finding and determined that the EOP and HVA are not distributed house-wide after annual review, nor are they accessible on the hospital's home internet page. The Emergency Management Committee will review the EOP and HVA to ensure hospital-specific risks and procedures are included in those documents by 4/24/2024. Review will include but not limited to, accurate department-specific response plans, hospital, local, state and federal contacts, results of actual events and planned drills, security and workplace violence data and local, state and national events as they may pertain to the hospital.

After review and approval by the EOC Committee, the Emergency Management Director will email instructions to all staff on how to access the EOP and HVA to all staff on the hospital's internet home page by 4/25/2024.
Copies of the EOP and HVA are on file in the Incident Command Center and with the Emergency Management Director.

Ongoing Compliance:
To promote further awareness of the hospital's Emergency Management Program, the training module presented at new employee orientation will become a required annual training through the hospital's online education platform, Steward University. The training module and quiz will be posted by 5/17/2024.

Annually, the Emergency Management Committee will review the EOP for hospital-specific hazards and update the EOP before distribution. The training module and quiz for new and current employees will be updated based on the review.

Monitoring:
The Emergency Management Director will present the updated EOP to the EOC and Quality Committees for review and approval at the next meeting. Completion rates of the Steward University training/quiz will be presented to the EOC and Quality Committees until 100% compliance is achieved. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible: Emergency Management Director

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on March 13, 2024, at 1:30 p.m., revealed the facility failed to provide annual emergency management training and testing documentation that reflected the risks identified in the facility's hazard assessment, per regulations. The facility had documentation of the general corporate training program, but site-specific elements were not incorporated within the program.

Interview with the administrator and director of environmental services on March 13, 2024, at 1:30 p.m., confirmed the emergency preparedness plan did not include the above elements at the time of the survey.

Plan of Correction - To be completed: 05/17/2024

The Emergency Management Director and Administrator reviewed the finding and determined that the EOP and HVA are not distributed house-wide after annual review, nor are they accessible on the hospital's home internet page. The Emergency Management Committee will review the EOP and HVA to ensure hospital-specific risks and procedures are included in those documents by 4/24/2024. Review will include but not limited to, accurate department-specific response plans, hospital, local, state and federal contacts, results of actual events and planned drills, security and workplace violence data and local, state and national events as they may pertain to the hospital.

After review and approval by the EOC Committee, the Emergency Management Director will email a copy of the EOP and HVA to all staff with instructions on how to access these on the hospital's internet home page by 4/16/24.
Copies of the EOP and HVA are on file in the Incident Command Center and with the Emergency Management Director.

Ongoing Compliance:
To promote further awareness of the hospital's Emergency Management Program, the training module presented at new employee orientation will become a required annual training through the hospital's online education platform, Steward University. The training module and quiz will be posted by 5/17/2024.

Annually, the Emergency Management Committee will review the EOP for hospital-specific hazards and update the EOP before distribution. The training module and quiz for new and current employees will be updated based on the review.

Monitoring:
The Emergency Management Director will present the updated EOP to the EOC and Quality Committees for review and approval at the next meeting. Completion rates of the Steward University training/quiz will be presented to the EOC and Quality Committees until 100% compliance is achieved. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible: Emergency Management Director

482.15(e), 483.73(e), 485.542(e), 485.625(e) STANDARD Hospital CAH and LTC Emergency Power:

§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 on March 13, 2024, at 1:37 p.m., revealed the facility Emergency Preparedness Plan lacked a site-specific program that clearly outlines an emergency power program based on the risk assessment and corresponding policies and procedures. Additionally, through document review and interview, it was revealed the generators were not being maintained, inspected, and tested per NFPA 101, 99, and 110.

Interview with the regional director of facilities on March 13, 2024, at 1:37 p.m., confirmed the Emergency Preparedness Plan did not include a site-specific program to meet all the required standards.

Plan of Correction - To be completed: 05/16/2024

1. The Emergency Management Director and Regional Facilities Director reviewed the EOP's Annex B Response Guides for Specific Incidents and found that the stated procedures are not specific to the hospital. On 4/12/2024, the EM Director and Regional Facilities Director completed a facility specific emergency power and generator fuel plan that includes backup systems, modifications/continuity of care, operations significantly impacted up to evacuation. This grid will be maintained as part of the EOP.

2. The Regional Facilities Director will follow the corrective action plans for the generator maintenance Tag K918 for weekly visual inspections, monthly conductance testing, load banks, annual fuel quality and follow up on repairs/issues.

Ongoing Compliance:
The utilities disruption grid will be expanded to include a plan for all utility disruptions outlined in NFPA 99-2010 Chapter 12. The evaluation will be completed and reviewed/approved by the EOC Committee by 5/16/2024.

This grid will be reevaluated annually with the EOP, taking into consideration generator failures, incidents involving activating the EOP, the MOU for fuel delivery and any other disruptions to general generator function.

The Regional Facilities Director will follow the corrective action plans for the generator maintenance Tag K918 for weekly visual inspections, monthly conductance testing, load banks, annual fuel quality and follow up on repairs/issues.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes document review. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

Monitoring:
1.& 2. The Emergency Management Director will present the utilities disruption grid to the EOC and Quality Committees for review and approval at the next meeting and annually thereafter with the EOP. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible: Emergency Management Director

Initial comments:Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0000

Facility ID # 196601
Component 01
B/C Building

Based on an onsite survey that was part of a unannounced compliant investigation completed on March 12-14, 2024, it was determined that Sharon Regional Health System was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

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

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0100

Based on observation and interview, the facility failed to maintain general requirements that are not addressed by the provided K-tags, but are deficient, affecting one of four building components.
Findings include:
1. Observation on March 13, 2024, between 10:29 a.m. and 11:07 a.m., revealed the facility was using a large portion of the fifth floor for a storage area. There were multiple patient rooms being used to store various combustible items, such as bed frames with mattress, wheelchairs, general medical equipment, etc. The change in use was done without Department of Health State Plan Review approval, as well as an occupancy from the Division of Life Safety. Additionally, the facility was using the floor as a repository for spare parts, including patient headwalls and other accessories. Further observations displayed water damaged ceiling tiles in several locations, illustrating evidence of roof leaks.
Interview with the regional director of facilities on March 13, 2023, at 11:07 a.m., confirmed the above floor was being used as storage and there was no documentation indicating they had State Plan Review approval, or granted occupancy from Life Safety Division.
2. Document review on March 13, 2024, at 2:25 p.m., revealed the facility completed a self-reported event indicating there was a nonfunctioning generator at 12:21 p.m., on 12/21/21. The event description also indicated that the generator was restored at 8:32 p.m., on 12/21/21. Through observation and interview, it was communicated that the facility installed and is currently using a temporary generator for the failed, " Generator #1 " . The facility failed to follow-up with a notification to the Division of Safety Inspection that a temporary generator was installed following the event reported on 12/21/21.
Interview with the regional director of facilities on March 13, 2023, at 2:25 p.m., confirmed the facility failed to notify the Division of Safety Inspection that Generator #1 failed following the self-reported event and a temporary generator was installed.

Plan of Correction - To be completed: 04/15/2024

1.
The excessive storage was evaluated and will be discarded or appropriately relocated by 4/15/24.
The stained ceiling tiles were replaced on 3/28/24. The source of leaks were identified and remediated.

Ongoing Compliance:
All closed patient units were assessed for storage; none were identified. The EOC rounding tool was updated to include identifying storage in licensed patient rooms. Front line leaders were educated on not storing equipment in unused patient units. The Regional Facilities Director verified that stained ceiling tiles are listed on the EOC rounding tool. The multidisciplinary EOC rounding team was educated on the findings including escalating inappropriate storage and evidence of moisture above the ceiling to the Regional Facilities Director and to hospital leadership.

2.
The Regional Facilities Director was unaware of the requirement to report the temporary generator to the Division of Safety. A report was made to PA Department of Health/Jackson Center Field Office Supervisor, Jeffery A. Devault on 4/12/24 at 11:00 am that the temporary generator was in place.
The departmental orientation checklist has been edited to include "notification to the PD DOH/Safety Division if temporary utilities equipment is in required along with installation date."

Ongoing Compliance:
Moving forward, the Regional Facilities Director will notify the Senior Leadership Team and Division of Safety of any temporary utilities equipment upon equipment failure to confirm order and installation dates. Temporary utilities undergo the same preventative maintenance as permanent equipment to ensure proper maintenance activities. These activities are monitored through the work order system.

Monitoring:
EOC rounding will take place monthly on the 5th floor monthly for 3 consecutive months or until 100% compliance is achieved. Results will be presented to the EOC and Quality Committees and minutes are forwarded to the Board of Directors for review and recommendations. EOC rounds are reported ongoing to the EOC and Quality Committees.

The Regional Facilities Director will report any temporary utilities equipment to the EOC and Quality Committees along with the close maintenance work orders. Minutes are forwarded to the BOD for review and recommendation.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Multiple Occupancies - Construction Type:

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0133

Based on observation and interview, the facility failed to ensure the division of building construction types, on one of four building levels.
Findings include:
Observation on March 12, 2024, at 10:01 a.m., revealed the first floor, two hour rated firewall, above the fire doors between buildings C and E, had a large penetration (approximately 10" X 10") around two sections of insulated piping.

Interview with the regional director of facilities and maintenance supervisor on March 12, 2024, at 10:01 a.m., confirmed the above penetration existed in the rated walls.

Plan of Correction - To be completed: 05/15/2024

On 3/19/24, the fire wall penetration was appropriately sealed/fire stopped.

Ongoing Compliance:
The Facilities staff will inspect above the fire doors noted on the life safety plans by 5/15/24 and seal/fire stop any fire wall penetrations. Facilities staff were re-educated on the Above Ceiling Permit process used when hospital staff or a vendor perform above ceiling work. Facilities staff are required to inspect fire walls for fire wall penetrations before the ceiling is closed and the permit is signed off.

Monitoring:
The Facilities Director reviews open and closed Above Ceiling Permits at the monthly EOC, Quality Committee, and Board of Directors meetings. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

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: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0161

Based on observation and interview, the facility failed to maintain building construction type and height on all building levels.

Findings include:

1. Observation on March 12, 2024, at 9:45 a.m., revealed the facility had encapsulated wood within the floor/ceiling assembly on the first floor (corridor outside the cafeteria) and second floor (corridor outside the lab), with smoke detectors within the interstitial space.

Interview with the regional director of facilities on March 12, 2024, at 9:45 a.m., confirmed the encapsulated wood within the floor/ceiling assembly on two building levels.

2. Observation on March 12, 2024, at 9:50 a.m., revealed the facility construction type did not meet the requirements for the story height throughout the building.

Interview with the regional director of facilities on March 12, 2024, at 9:50 a.m., confirmed the construction type did not meet the requirements for the story height.

Plan of Correction - To be completed: 04/15/2024

On 2/26/14, the Pennsylvania Department of Health provided a Fire Safety Evaluation System (FSES) to Sharon Regional Medical Center. The FSES confirms that the 13 parameters evaluated for floors 1-6, 25 zones and each smoke compartment meets K/S structural wood and K/S travel distance greater than 200 feet from any point in a smoke compartment to a required smoke barrier door. The hospital maintains this record on file. The document is available for review. The Regional Facilities Director did not have this document on hand during survey for review.

Ongoing Compliance:
The FSES will be filed in the Leadership document retention binder in the Facilities Office and a copy will also be kept in the office of the hospital President to ensure its availability during survey.

Monitoring:
The FSES will be presented to the next EOC and Quality Committees and forward to the BOD meeting along with the committee minutes for record. Any future construction will be approved by the Pennsylvania Department of Health Plan Review.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0291

Based on observation and interview, the facility failed to maintain emergency lighting, in accordance with regulations, affecting four of four building components.

Findings include:

1. Observation on March 12, 2024, between 11:26 and 11:45 a.m., revealed the following battery pack emergency lighting units did not illuminate when the test button was depressed:
A. (11:26 a.m.) Powerhouse #1, emergency light numbers 15, 17, 18, and 20;
B. (11:45 a.m.) Kitchen, emergency light number 28.

Interview with the maintenance supervisor on March 12, 2024, at 11:45 a.m., confirmed the above battery-pack emergency lighting units were not functioning at the time of the survey.
2. Document review on March 13, at 9:20 a.m., revealed the most recent annual ninety-minute emergency light test (conducted on October 3, 2024) noted 20 emergency light failures. The facility could not produce documentation that the emergency lights were repaired at the time of the survey.
Interview with the regional director of facilities on March 13, 2024, at 9:20 a.m., confirmed that the facility lacked documentation that repairs for the emergency lights was not available at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

Correction:
1A: The Radiology Department emergency light that failed during survey and will be operational by 5/15/24

1B: The annual emergency lights testing has a target completion date of 5/30/24.

Ongoing Compliance:
1A & 1B: A new work order system was implemented in early 2024. The system is designed to automatically create a corrective maintenance work order for failed devices. The Regional Facilities Director reviewed the findings with the Facilities staff who conduct annual emergency light testing to close out auto-generated work orders when deficiencies are corrected. Any deficiency that cannot be corrected within an 8-hour shift will have an ILSM with staff educated completed.

Monitoring
1A & 1B: The Regional Facilities Director will review and approve the closed annual 90-minute preventative and corrective maintenance work orders and present to the EOC and Quality Committees for 3 consecutive months or until 100% compliance is achieved. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit signs for three of five floors.

Findings include:

1. Observation on March 12, 2024, between 10:13 a.m. and 1:50 p.m., revealed the following exit sign deficiencies:
A. (10:13 a.m.) first floor, South exit discharge door, located next to the pharmacy, had a missing exit sign;
B. (10:50 a.m.) first floor, stairwell tower located next to the electrical rooms and in close proximity to the dining area, had both the North and South double doors, lacking directional exit signs that would allow site continuity when the doors are in the closed position;
C. (1:39 p.m.) second floor, south door to the laboratory had a missing exit sign;
D. (1:49 p.m.) second floor, double doors, at heart and vascular area, was lacking a directional exit sign that would allow site continuity when the doors are in the closed position;
E. (1:50 p.m.) second floor, double doors, at heart and vascular area, exit placard attached to door was not illuminated;

Interview with the maintenance technician March 13, 2024, at 1:50 p.m., confirmed the above exit sign deficiencies existed at the time of the survey.

2. Observation on March 13, 2024, between 9:34 a.m. and 10:21 a.m., revealed the following exit sign deficiencies:
A. (9:34 a.m.) fourth floor, corridor at fire tower "B", exit sign was lacking directional chevron;
B. (10:00 a.m.) fourth floor, door to child psychiatric unit, had an exit sign with arrows displayed in the wrong direction (opposite direction of the proper exit);
C. (10:21 a.m.) fourth floor, " sally port " door to elevator #3, was missing an exit sign.

Interview with the maintenance technician March 13, 2024, at 10:21 a.m., confirmed the above exit sign deficiencies existed at the time of the survey.

Plan of Correction - To be completed: 05/19/2024

Corrective Actions:
Finding 1:
A. first floor, South exit discharge
door, located next to the pharmacy, had a
missing exit sign: will be installed and added to the inventory by 4/30/24

B. first floor, stairwell tower located
next to the electrical rooms and in close proximity
to the dining area, had both the North and South
double doors, lacking directional exit signs that
would allow site continuity when the doors are in
the closed position: current signs will be replaced with direction exit signs installed and added to the inventory by 4/30/24

C. second floor, south door to the
laboratory had a missing exit sign: will be installed and added to the inventory by 4/30/24

D. second floor, double doors, at
heart and vascular area, was lacking a directional
exit sign that would allow site continuity when the
doors are in the closed position: current signs will be replaced with directional exit signs and added to the inventory by 4/30/24

E. second floor, double doors, at
heart and vascular area, exit placard attached to
door was not illuminated: will be repaired by 4/30/24

Finding 2:
A. fourth floor, corridor at fire tower
"B", exit sign was lacking directional chevron: current sign will be replaced with a directional sign by 4/30/24

B. fourth floor, door to child
psychiatric unit, had an exit sign with arrows
displayed in the wrong direction (opposite
direction of the proper exit): the current sign will be replaced with the correct directional arrow sign by 4/30/24

C. fourth floor, " sally port " door to
elevator #3, was missing an exit sign: an exit sign will be installed by 4/30/24.

Ongoing Compliance:
The Regional Facilities Director and Safety Officer will conduct a full building tour by 4/19/24 to evaluate exit signage and directional chevrons. The next monthly exit sign visual inspection is scheduled for 5/19/24. Any deficiencies will generate a corrective maintenance work order. If deficiencies cannot be addressed within 8 hours, an ILSM will be conducted with employee education, and notification to the Senior Leadership team. The Regional Facilities Director reviewed the EOC rounding tool and added directional signage and exit sign illumination to the tool. Staff conducting EOC rounds were educated to the updated tool prior to rounding.

Monitoring:
The Regional Facilities Director will review and approve the monthly exit sign testing preventative and corrective maintenance work orders and present to the EOC and Quality Committees for 3 consecutive months or until 100% compliance is achieved. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Results of EOC rounding, preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Cooking Facilities:

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 three of three cooking facilities.

Findings include:

1. Document review on March 12, 2024, between 1:38 p.m. and 1:45 p.m., revealed the following kitchen deficiencies:
A. (1:38 p.m.) The facility lacked documentation to illustrate that the semi-annual suppression test/ maintenance was completed for the "bake shop" suppression system;
B. (1:40 p.m.) The facility lacked documentation to illustrate that the semi-annual hood/ duct cleaning was completed for the "bake shop";
C. (1:45 p.m.) The semi-annual hood/ duct cleaning report (dated January 24, 2023) indicated that the cleaning crew could not access the roof fans, as security did not have keys to access.

Interview with the regional director of facilities on March 12, 2024, at 1:45 p.m., confirmed the above kitchen system deficiencies existed on the day of the survey.

Plan of Correction - To be completed: 05/15/2024

A. The bake shop kitchen hood will be tested by 5/15/24.
B. The bake shop kitchen hood will be cleaned by 5/15/24.
C. Security staff has always had keys to the roof fans. The Security manager will meet with the Security team and review key access for roof fan areas to ensure all team members are aware by 4/19/24.

Ongoing Compliance:
A-B: The Regional Facilities Director reviewed previous reports and communications with vendors for kitchen hood testing and cleaning and determined that neither vendor was providing scheduled preventative maintenance activities. New local vendors have been identified who will provide these services for the hospital.

C. All Security personnel have keys to access the roof so that the fans can be tested during cleaning. Security staff were educated on the location of the door leading to the fans to escort the vendor moving forward. The fans will be cleaned by 5/15/24.

A-C:
The Regional Facilities Director will escalate issues with on time testing and cleaning to the Senior Leadership if these services will be out of compliance due to vendor scheduling. The Regional Facilities Director confirmed there are preventative maintenance work orders for both and these services.

Monitoring:
The Regional Facilities Director will review and approve the semiannual preventative maintenance work orders and testing and cleaning reports and present these to the EOC, Quality Committees, and Board of Directors. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

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: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0353

Based on observation and interview, it was determined that the facility failed to remain in compliance with sprinkler system requirements, affecting the entire component.
Findings include:
1. Observation on March 12, 2024, at 11:15 a.m., revealed the dumbwaiter shaft had combustible material being used to close an opening on the bottom section of the shaft. With the shaft being accessible and the presence of combustible materials being used, it was lacking sprinkler head protection at the top of the shaft.
Ref: NFPA 13 - 8.15.2.1
Interview with the maintenance supervisor on March 13, 2024, at 11:46 a.m., confirmed the above deficiency existed.

2. Observation on March 13, 2024, at, 10:29 a.m., revealed fifth floor, stair tower C-1, had a remote operated valve that was chained and locked in the closed position, preventing the valve from being opened during an emergency.
Interview with the maintenance supervisor on March 13, 2024, 2024, at, 10:29 a.m., confirmed the valve was chained in the locked position and could not be operated remotely in an emergency.

Plan of Correction - To be completed: 05/30/2024

Correction:

1. On the day of survey, the dumbwaiter shaft had combustible material being used to close an opening on the bottom section of the combustible shaft. With the shaft being accessible and presence of combustible materials being used, it requires sprinkler head protection at the top of the shaft. The sprinkler head will be installed by 5/30/24.

2. The fifth floor, stair tower C-1 had a remote operated valve that was chained and locked in the closed position, preventing the valve from being opened during an emergency. The deficiency was immediately corrected on 3/13/24 with the valve chained in the open position.

A monthly preventive maintenance (PM) work order was entered on 4/12/24 to visually inspect all valves to ensure they are chained in the open position.

Ongoing Compliance:
1. The additional sprinkler head will be added to the inventory and inspected/tested as required. Any deficiencies noted on a sprinkler report require an ILSM and correction within 60 days.

2. Following the survey, the Regional Facilities Director reviews, approves and closes the monthly visual valve inspection work order.

1 & 2
Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes checking that shafts and chutes have required sprinkler coverage and that the sprinkler head is not dirty or corroded as well as spot checking that remotely operated valves are chained in the open position, so they are available in an emergency. Any sprinkler heads or valves that do not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

Correction:
1. During the survey document review it was observed that the five-year internal valve and pipe inspection was not completed at the time of survey. The five-year internal valve and pipe inspection has a target date of completion of 5/30/24.

Ongoing Compliance:
Following the survey, a preventative maintenance (PM) work order was updated to print in March 2029 to schedule the five-year internal valve and pipe inspection for April 2029.

Following the survey, the Facilities Director reviews, approves and closes the five-year internal valve and pipe inspection documentation.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any five-year internal valve and pipe inspection documentation that does not meet regulatory requirements will be reviewed with the Facilities Director. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection or testing and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection or testing and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Portable Fire Extinguishers:

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

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0355

Based on document review and interview, it was determined that the facility failed to remain in compliance with annual fire extinguisher inspections, affecting the entire facility.

Findings include:

Observation on March 13, 2024, at 9:40 a.m., revealed the facility lacked documentation that an annual fire extinguisher inspection was performed within the last year. The last documented inspection was conducted on November 28, 2022.

Interview with the regional director of facilities on March 13, 2024, at 9:40 a.m., confirmed the above portable fire extinguisher inspection documentation was not on-site at the time of the survey.

Plan of Correction - To be completed: 04/13/2024

During the survey document review it was observed that the annual fire extinguisher inspection had not occurred since 11/28/2022. This was due to a change in fire alarm/sprinkler testing vendors. The annual fire extinguishers were inspected by the new vendor. All fire extinguishers will be inspected by 4/13/24.

Ongoing Compliance:
Following the survey, a preventative maintenance (PM) work order was updated to print in March each year to schedule the annual fire extinguisher inspection for April.

Following the survey, the Facilities Director reviews, approves and closes the annual fire extinguisher inspection documentation.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any annual fire extinguisher inspection documentation that does not meet regulatory requirements will be reviewed with the Facilities Director. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: 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. Observations on March 12, 2024, between 9:42 a.m. and 2:12 p.m. and March 13, 2024, between 9:19 a.m. and 11:11 a.m. revealed there were numerous lay in ceiling tiles throughout the facility that were damaged, missing, or misaligned within the suspended grid system. The openings in the ceiling tiles allow passage of smoke and can delay the activation of smoke detection or the sprinkler head function.

Interview with the maintenance supervisor on March 12-13, 2024, at 11:11 a.m., confirmed the above ceiling tile deficiencies existed at the time of the survey.
2. Document review on March 12, 2024, at 10:25 a.m., revealed the last documented smoke/ fire damper inspection report (completed 3/14/23 to 5/7/23) noted multiple deficiencies. The spreadsheet within the report indicated fifty deficiencies and the facility verified that fourteen were repaired internally. There was no documentation to confirm that the remaining dampers were corrected at the time of the survey. The facility indicated that a contractor was required to complete the repairs and they were scheduled for services on June 6, 2024.

Interview with the regional director of facilities on March 12, 2024, at 10:25 a.m., confirmed the facility lacked documentation to verify the deficiencies in the report were corrected at the time of the survey.

Plan of Correction - To be completed: 06/04/2024

1. All missing and misaligned ceiling tiles within the grid were corrected by 3/15/24.
All damaged ceiling tiles are replaced as identified. The Lab ceiling tiles are planned to be replaced by 4/30/24.

2. During the survey document review it was observed that the last documented smoke/fire damper inspection report completed 5/7/2023 noted 50 deficiencies and 14 that were repaired internally. The scheduled vendor was contacted to move up the date and the remaining 36 deficiencies were corrected by 6/4/24.

Ongoing Compliance:
1. Open for Business (OFB) rounds are conducted weekly by Department Managers/designee. The inspection of damaged, missing or significant gaps in ceiling tiles resulting in the disruption of the ceiling membrane is included on the rounding tool. Deficiencies are corrected immediately, or a corrective work order is issued.

The Regional Facilities Director reviewed the EOC rounding tool and missing, damaged or significant gaps in ceiling tiles is on the tool.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes checking that ceiling tiles are not missing, damaged or misaligned within the grid. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

2. The Regional Facilities Director was re-educated that life safety deficiencies need to be addressed immediately.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any smoke/fire damper documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

Monitoring:
1 & 2
The Regional Facilities Director will present OFB and EOC rounding data and the damper repair report to the EOC and Quality Committees the month following inspection and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Elevators:

Elevators
2012 EXISTING
Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record.
Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.)
19.5.3, 9.4.2, 9.4.3

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0531

Based on observation and interview, the facility failed to maintain the elevator machinery room, for one of five elevator machinery rooms.
Findings include:
Observation on March 12, 2024, at 10:20 a.m., revealed the elevator machinery room, had excessive oily rags and oil in an open bucket and on the floor, and a missing grill for the exhaust duct, lacks housekeeping for the hazardous room.

An interview with the maintenance supervisor on March 12, 2024, at 10:20 a.m., confirmed the above discrepancies.

Plan of Correction - To be completed: 04/19/2024

The day of survey, the oily rags and oil in an open bucket on the floor were removed and the missing grill for the exhaust duct was replaced. The Regional Facilities Director identified the lack of a monthly PM for Facilities staff to regularly inspect hazardous rooms.

Ongoing Compliance:
Following the survey, a preventative maintenance (PM) work order was created for Facilities staff to inspect hazardous rooms monthly.

By 4/19/24, the Regional Facilities Director will educate the Facilities staff and elevator vendor management staff to ensure there is no inappropriate storage of items and flammable materials in hazardous rooms and mechanical systems need to be maintained. In addition, the Regional Facilities Director will contact the vendor's management to review expectations of housekeeping matters.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Mechanical/hazardous rooms are evaluated and those rooms that do not meet regulatory requirements will be reviewed with the Facilities Director. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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 on March 12, 2024, at 1:06 p.m., revealed the most recent smoke and fire door annual inspection (conducted May 23, 2023) noted 23 door failures. The facility did not provide documentation that the door failures were repaired at the time of the survey. The facility indicated that a contractor was scheduled to repair the doors beginning on March 14, 2024.

Interview with the regional director of facilities on March 12, 2024, at 1:06 p.m., confirmed the above door repair documentation was not available at the time of the survey.

Plan of Correction - To be completed: 05/15/2024

1.Correction:
During the survey document review it was observed that the fire door repairs were not addressed following testing at the main campus due to vendor non-payment. There was a change in the Facilities Manager position and the door repairs were not scheduled. The vendor has been paid and contacted to commence the door repairs. Work is expected to begin by 5/15/24.

During survey, the annual fire door inspection report could not be located. Following survey, the Regional Facilities Director contacted the vendor, who provided the report dated 6/2/23. There were two failed doors identified on the report. The repairs will be completed along with the main campus repairs scheduled to begin 3/14/24.

Ongoing Compliance:
Moving forward the Regional Facilities Director/Manager will enter failed fire doors in the work order system and close them when repairs are completed to track progress. The Regional Facilities Director will escalate vendor issues to hospital Senior Leadership.

The Regional Facilities Director will file the annual fire door reports in the Fire/Life Safety documentation binder for the Cancer Center and maintain a copy on the Facilities shared drive. The Regional Facilities Director will also enter a work order to generate every May for the June testing.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any inspection documentation that does not meet regulatory requirements will be reviewed with the Facilities Director. The next scheduled survey is December 2024.

2.Correction:
During survey, the annual fire door inspection report could not be located for the surveyor. Following survey, the Regional Facilities Director contacted the fire door testing vendor, who provided the report dated 6/2/23. There were two failed doors identified on the report. The repairs will be completed along with the main campus repairs scheduled to begin 3/14/24.

Ongoing Compliance:
The Regional Facilities Director will file the annual fire door reports in the Fire/Life Safety documentation binder for the Cancer Center and maintain a copy on the Facilities shared drive. The Regional Facilities Director will also enter a work order to generate every May for the June testing. Moving forward the Regional Facilities Director/Manager will enter failed fire doors in the work order system and close them when repairs are completed to track progress. The Regional Facilities Director will escalate vendor issues to hospital Senior Leadership.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any inspection documentation that does not meet regulatory requirements will be reviewed with the Facilities Director. The next scheduled survey is December 2024.

Monitoring:
1.The Regional Facilities Director will review annual fire door reports and closed work orders for repairs and present to the EOC and Quality Committees until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.
2.The Regional Facilities Director will review fire door reports and closed work orders for repairs and present to the EOC and Quality Committees until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:

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 on March 12, 2024, at 2:35 p.m., revealed the facility lacked documentation that an annual medical gas inspection was performed within the last year. The last documented inspection was completed on January 13, 2022, and there were deficiencies recorded in all three severity priorities (Urgent, High, and Low) within the report. The deficiency summary list included the following items:
1. Alarms:
A. "Nursery is required to have an area alarm for oxygen, air and vacuum." Noted as an Urgent priority.
2. Zone Valves:
A. "7 Vacuum and 1 oxygen zones are missing zone valves. Install valves with new construction." Noted as a Low priority.
B. "14 valves leaking during opening and closing of valves. Replace with new construction." Noted as a Low priority.
C. "The CVU should have its own Zone Vales for Oxygen and Vacuum." Noted as a Low priority.
D. "2 valve boxes are obstructed because they are behind an open door and require correction." Noted as a High priority.

Interview with the regional director of facilities on March 12, 2024, at 2:35 p.m., confirmed the facility lacked an updated annual medical gas inspection and documentation that verifies the above deficiencies were corrected at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

During the survey document review it was observed that the last documented medical gas testing was completed on 1/13/22 and there were several deficiencies noted. There was also no test report provided for 2023. The vendor completed medical gas inspection 4/2/24 and awaiting final report. Deficiencies will be completed by 5/30/24.

Ongoing Compliance:
The Regional Facilities Director entered a work order for annual medical gas testing to generate in March every year and will be closed out when testing is complete. Work orders will be generated for deficiencies to track completion.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any utility documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will present the annual medical gas report and subsequent repairs to the EOC and Quality Committees the month following testing/repairs and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Electrical Systems - Other:

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: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0911

Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, in one of over five electrical rooms.

Findings include:

Observation on March 12, 2024, at 11:28 a.m., revealed the first-floor powerhouse#1, temporary emergency generator cables were installed without protection from accidental damage. The cables were directed through a doorway with a pinch-point and sharp edges. The exterior cables were not protected from possible damage by crushing, or other damage.

Reference: NFPA 70-590.4(H)

Interview with the maintenance supervisor and compliance officer on March 12, 2024, at 11:28 a.m., confirmed the above unprotected cables were present at the time of the survey.

Plan of Correction - To be completed: 04/17/2024

The Regional Facilities Director reviewed the NFPA 70-590.4(H) "flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protection shall be provided to avoid damage." A solution has been identified to protect the cables from accidental damage and was implemented by the Facilities team on 4/15/24.

Ongoing Compliance:
By 4/17/24, the Regional Facilities Director will educate the Facilities staff on the NFPA 70-590.4(H) requirement that the generator cables need to be properly protected. After the work is completed, the Regional Facilities Director will enter a weekly work order for Facilities staff to inspect the cables to ensure they remain properly protected.

Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection and until 100% compliance is achieved. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Electrical Systems - Receptacles:

Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

Plan of Correction - To be completed: 05/30/2024

1.
Correction:
Upon reviewing the finding, the Regional Facilities Director identified the lack of a process to identify the need for GFCIs within 6' of a water source throughout the hospital. GFCIs will be installed at all deficient locations by 4/30/24.

Ongoing Compliance:
The Regional Facilities Director will provide education to the Facilities staff by 4/17/24 regarding the need for GFCIs to be installed within 6' of a water source. Appliances should be evaluated during the initial electrical inspection prior to use.

A full building assessment will be completed by house electricians by 5/30/24.

The Regional Facilities Director added GFCIs within 6' of a water source to the EOC rounding tool. Staff who are members of the EOC rounding team were educated prior to conducting rounds.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes checking for GFCIs in wet locations. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

2.
Correction:
Upon reviewing the finding, the Regional Facilities Director identified the lack of a process to identify the need for GFCIs within 6' of a water source throughout the hospital. GFCIs will be installed at all deficient locations by 4/30/24.

Ongoing Compliance:
The Regional Facilities Director will provide education to the Facilities staff by 4/17/24 regarding the need for GFCIs to be installed within 6' of a water source. Appliances should be evaluated during the initial electrical inspection prior to use.

A full building assessment will be completed by house electricians by 5/30/24.

The Regional Facilities Director added GFCIs within 6' of a water source to the EOC rounding tool. Staff who are members of the EOC rounding team were educated prior to conducting rounds.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes checking for GFCIs in wet locations. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

3.
Correction:
Upon reviewing the finding, the Regional Facilities Director identified the lack of a process to identify the need for GFCIs within 6' of a water source throughout the hospital. GFCIs will be installed at all deficient locations by 4/30/24.

Ongoing Compliance:
The Regional Facilities Director will provide education to the Facilities staff by 4/17/24 regarding the need for GFCIs to be installed within 6' of a water source. Appliances should be evaluated during the initial electrical inspection prior to use.

A full building assessment will be completed by house electricians by 5/30/24.

The Regional Facilities Director added GFCIs within 6' of a water source to the EOC rounding tool. Staff who are members of the EOC rounding team were educated prior to conducting rounds.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes checking for GFCIs in wet locations. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

Monitoring:
1.The Regional Facilities Director EOC rounding data is a standing agenda item for the EOC and Quality Committees. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.
2.The Regional Facilities Director EOC rounding data is a standing agenda item for the EOC and Quality Committees. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.
3.The Regional Facilities Director EOC rounding data is a standing agenda item for the EOC and Quality Committees. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0918

Based on observation and interview the facility failed to meet electrical system requirements for one of six generators.

Findings include:

Based on observation on March 13, 2024 at 11:01 a.m. revealed that generator #1 annunciator panel failed to operate when tested. The lamp/sound test buttons did not operate when tested.

Interview with maintenance tech on March 13, 2024 at 11:01 a.m. confirmed the annunciator panel failed to operate when tested.

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

Findings include:

Documentation review on March 13, 2024, between 1:37 p.m. and 2:50 p.m., revealed the following generator deficiencies:
A. (1:37 p.m.) the facility generator reports did not include monthly battery electrolyte-specific gravity or conductance testing;
B. (1:59 p.m.) the facility lacked documentation that an annual fuel quality was performed within the last year. The most recent documented inspection was conducted on December 22, 2022.
C. (2:50 p.m.) the annual load bank and data forms provided on the day of the survey indicated the batteries need attention;
D. (2:50 p.m.) the facility lacked documentation that a four-hour load test was completed for generator #5 and #8 at the time of the survey.

Interview with the regional director of facilities on March 13, 2024, at 2:50 p.m., confirmed the above generator deficiencies existed at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

Correction:
1. The temporary generator was not tied into the annunciator panel when it was installed. The Regional Facilities Director contacted the vendor who installed the generator. The repair has a tentative date of 4/26/24. At this time the vendor will tie the temporary generator into the annunciator panel. During monthly generator testing, the "remote alarms received" section of the form was incomplete; this section verifies the alarm signal is received at the panel.

A. The Regional Facilities Director confirmed conductance testing was not completed on the generators. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Effective immediately, the Regional Facilities Director will ensure conductance testing is being completed on each generator and reflected on the forms accordingly. The Regional Facilities Director will review the forms for completeness prior to filing.

B. The Regional Facilities Director confirmed that annual fuel quality testing due in December 2023 is late due to vendor payment issues. The vendor has been paid and contacted to move forward with regular testing and maintenance. The annual fuel quality test is anticipated to be accomplished by 5/15/2024.

C. The Regional Facilities Director confirmed that the generator's annual load bank had battery issues that were not addressed. The Regional Director contacted the vendor on 4/15/24 to replace the generator batteries.

D.The Regional Facilities Director confirmed the late load bank testing is due to payment issues. The vendor was paid and contacted on 4/15/24 to schedule load bank testing and regular maintenance for all generators. The 4-hour load banks are anticipated to be accomplished by 5/30/24.

Ongoing Compliance:
1. The Regional Facilities Director will educate the Facilities staff who perform generator monthly testing on the requirement that receipt of the local and remote alarms must be documented. Education included reviewing the alarm sections on the form that need to be completed. Any issues should be immediately escalated to the Regional Facilities Director. All staff were trained by 4/17/24. Any barriers incurred to accomplishing this testing or maintenance will be communicated to the Senior Leadership Team immediately.

The Regional Facilities Director will review the monthly generator test forms to confirm receipt of remote and local alarms are documented. Any non-compliance will result in re-education.

A. The Regional Facilities Director will educate the Facilities staff who perform generator monthly testing on the requirement that monthly conductance testing must be documented. The education consisted of reviewing the form, use of the meter and documentation. All staff were trained by 4/17/24.

The Regional Facilities Director will review the monthly generator forms to confirm conductance testing is complete on all generators. Any non-compliance will result in re-education.

B. The Regional Facilities Director entered a work order for annual fuel quality testing to generate in November every year and will be closed out when testing is complete. Work orders will be generated for deficiencies to track completion. Any issues with scheduling will be escalated to hospital Senior Leadership.

C. & D. The Regional Facilities Director entered a work order for annual load bank testing for each generator a month prior to the due date; work orders will be closed out when testing is complete. Work orders will be generated for deficiencies to track completion. Any issues with scheduling will be escalated to hospital Senior Leadership.

A.-D.
Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any utility documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director.

Correction:
A. The Regional Facilities Director confirmed that weekly visual generator inspections were not being conducted. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Moving forward, the Regional Facilities Director will review the weekly forms for completeness and train the new Manager on the requirement and procedure to review the forms prior to filing.

Ongoing Compliance:
A. The Regional Facilities Director will educate the Facilities staff who perform generator monthly testing on the requirement that monthly conductance testing must be documented. The education consisted of assuring all required elements of testing were completed, reviewing the form, use of the meter and documentation. All staff were trained by 4/17/24.

A. The Regional Facilities Director will review the monthly generator forms to confirm conductance testing is complete on all generators. Any non-compliance will result in re-education.

Page 53 #2 A-D:

Correction:
A. The Regional Facilities Director confirmed that weekly visual generator inspections were not being conducted. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Moving forward, the Regional Facilities Director will review the weekly forms for completeness and train the new Manager on the requirement and procedure to review the forms prior to filing.

B. The Regional Facilities Director confirmed conductance testing was not completed on the generator. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Moving forward, the Regional Facilities Director will review the form for completeness and train the new Manager on the requirement and procedure to review the form prior to filing.

C. The Regional Facilities Director confirmed that annual fuel quality testing due in December 2023, is late due to a change in the generator maintenance vendor due to non-payment resulting in a scheduling delay. The annual fuel quality test is anticipated to commence by 5/30/24. The result report is expected approximately two weeks after the test.

D. The Regional Facilities Director confirmed that the last annual load bank report had battery issues that were not addressed. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. It is anticipated that the batteries will be addressed by 5/30/24.

Ongoing Compliance:

A. The Regional Facilities Director will educate the Facilities staff who perform generator weekly visual inspections on the requirement that inspections must be consistently documented. The education consisted of reviewing the weekly inspection form listing the required elements. All staff will be trained by 4/17/24.

B. The Regional Facilities Director will educate the Facilities staff who perform generator monthly testing on the requirement that monthly conductance testing must be documented. The education consisted of reviewing the form, use of the meter and documentation. All staff will be trained by 4/17/24

A & B: The Regional Facilities Director will review the weekly and monthly generator forms to confirm weekly visual inspections and monthly conductance testing is complete on all generators. Any non-compliance will result in re-education.

C. The Regional Facilities Director entered a work order for annual fuel quality testing to generate in November every year and will be closed out when testing is complete. Work orders will be generated for deficiencies to track completion. Any issues with scheduling will be escalated to hospital Senior Leadership.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any utility documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.
D. The Regional Facilities Director entered a preventative maintenance (PM) work order for annual load bank testing for each generator a month prior to the due date and corrective maintenance work orders will be generated for deficiencies to track completion. Any issues with scheduling repairs will be escalated to hospital Senior Leadership.

Monitoring:
1, A-D
The Regional Facilities Director will present the closed work orders including any subsequent repair or follow-up issues to the EOC and Quality Committees the month following testing/repairs and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.
Monitoring: from page 53: The Regional Facilities Director will present the closed work orders to the EOC and Quality Committees the month following inspections until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.
1 A-D: The Regional Facilities Director will present approved generator inspections, testing and maintenance work orders and reports including any subsequent repair or follow-up issues to the EOC and Quality Committees the month following testing/repairs and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 01 - Tag: 0920

Based on observation and interview, the facility failed to maintain electrical power cords for one of five building levels.

Findings include:

Observation on March 12, 2024, between 1:20 p.m. and 1:26 p.m., revealed the following:
A. (1:20 p.m.) second-floor, blood bank, had laboratory medical equipment that was plugged into a surge protector;
B. (1:26 p.m.) second floor, laboratory, had laboratory medical equipment that was plugged into a surge protector.

Interview with the maintenance supervisor on March 12, 2024, at 1:26 p.m., confirmed the above deficiencies existed at the time of the survey.

Plan of Correction - To be completed: 04/30/2024

Correction:
A&B:
The Regional Facilities Director reviewed NFPA 99-12 10.2.4 standard regarding extension cords being used as permanent wiring for equipment. The cited areas were assessed, and it was determined that additional emergency outlets were needed. The emergency outlets will be added by 4/30/24, so that the two pieces of laboratory medical equipment will be plugged directly into outlets.

The Facilities house electricians will conduct a building tour to ensure that no permanent equipment is plugged into power strips; if issues are identified, outlets will be installed.

Ongoing Compliance:
A&B:
The Regional Facilities Director reviewed the EOC rounding tool and added correct use of power strips to the tool. Staff who conduct EOC rounds were educated prior to conducting rounds.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes checking that ceiling tiles are not missing, damaged or misaligned within the grid. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

Monitoring:
A&B:
The Regional Facilities Director will present EOC rounding data to the EOC, Quality Committee, and the Board of Directors for 4 consecutive months or until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

Initial comments:Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0000

Facility ID # 196601
Component 02
A Building

Based on an onsite survey that was part of a unannounced compliant investigation completed on March 12-14, 2024, it was determined that Sharon Regional Health System was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

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

Plan of Correction:

NFPA 101 STANDARD Dead-End Corridors and Common Path of Travel:

Dead-End Corridors and Common Path of Travel
2012 EXISTING
Dead-end corridors shall not exceed 30 feet. Existing dead-end corridors greater than 30 feet shall be permitted to be continued to be used if it is impractical and unfeasible to alter them.
19.2.5.2

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0251
Based on observation and interview the facility failed to meet dead end corridor requirements for one of six building levels.

Findings include:

Based on observation on March 13, 2024 at 11:44 a.m. revealed that the second floor, wing above the ER renovation, has a dead end corridor greater than 30 feet.

Interview with the maintenance tech on March 13, 2024 at 11:44 a.m. confirmed the dead end corridor exceeds thirty feet.

Plan of Correction - To be completed: 04/22/2024

The Regional Facilities Director reviewed the dead-end corridor finding with the Administrator and members of the Corporate Real Estate and Facilities team. The review consisted of assessing the life safety drawings. It was determined that this is not a corridor and is not reflected as such on the drawings. The drawings denote this area as one room, which is marked hazardous, consisting of a mechanical room, IT/Tele room and 678 square feet of storage. The room is sprinklered, has smoke detection and latching hardware on the doors. There is a smoke wall separation between this room and the Lab. The review determined that the hazardous room does not meet the definition of a dead-end corridor.

Ongoing Compliance:
The Regional Facilities Director conducted a full building assessment to identify dead-end corridors. None were found.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a building tour using the life safety drawings. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will present the building tour assessment of dead-end corridors to the EOC and Quality Committees. The CREF mock survey is presented to the EOC and Quality Committees the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0291

Based on observation and interview, the facility failed to maintain emergency lighting, in accordance with regulations, affecting four of four building components.

Document review on March 13, at 9:20 a.m., revealed the most recent annual ninety-minute emergency light test (conducted on October 3, 2024) noted 20 emergency light failures. The facility could not produce documentation that the emergency lights were repaired at the time of the survey.
Interview with the regional director of facilities on March 13, 2024, at 9:20 a.m., confirmed that the facility lacked documentation that repairs for the emergency lights was not available at the time of the survey.

Plan of Correction - To be completed: 04/26/2024

The annual 90-minute emergency light testing completed 10/3/23 did not have corrective work orders for the 20 failed lights, therefore, another 90-minute test will be completed by 4/26/24. All deficiencies have been corrected.

Ongoing Compliance:
A new work order system was implemented in early 2024. The system is designed to automatically create a corrective maintenance work order for failed devices. The Regional Facilities Director reviewed the finding with the Facilities staff who conduct annual emergency light testing to close out auto-generated work orders when deficiencies are corrected. Any deficiency that cannot be corrected within an 8-hour shift will have an ILSM implemented with staff educated, and notification to the Senior Leadership Team completed.

Monitoring:
The Regional Facilities Director will review and approve the closed annual 90-minute corrective maintenance work orders and present to the EOC and Quality Committees for 3 consecutive months or until 100% compliance is achieved. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates and EOC rounds are standing agenda items at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Portable Fire Extinguishers:

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0355

Based on document review and interview, it was determined that the facility failed to remain in compliance with annual fire extinguisher inspections, affecting the entire facility.

Findings include:

Observation on March 13, 2024, at 9:40 a.m., revealed the facility lacked documentation that an annual fire extinguisher inspection was performed within the last year. The last documented inspection was conducted on November 28, 2022.

Interview with the regional director of facilities on March 13, 2024, at 9:40 a.m., confirmed the above portable fire extinguisher inspection documentation was not on-site at the time of the survey.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0372

Based on observation and interview, the facility failed to meet requirements for smoke resistant barriers, to resist the passage of smoke, affecting six of six building levels.

Findings include:

Document review on March 12, 2024, at 10:25 a.m., revealed the last documented smoke/ fire damper inspection report (completed 3/14/23 to 5/7/23) noted multiple deficiencies. The spreadsheet within the report indicated fifty deficiencies and the facility verified that fourteen were repaired internally. There was no documentation to confirm that the remaining dampers were corrected at the time of the survey. The facility indicated that a contractor was required to complete the repairs and they were scheduled for services on June 6, 2024.

Interview with the regional director of facilities on March 12, 2024, at 10:25 a.m., confirmed the facility lacked documentation to verify the deficiencies in the report were corrected at the time of the survey.

Plan of Correction - To be completed: 06/04/2024

During the survey document review it was observed that the last documented smoke/fire damper inspection report completed 5/7/2023 noted 50 deficiencies and 14 that were repaired internally. The scheduled vendor was contacted to move up the date and the remaining 36 deficiencies will be corrected by 6/4/24.

Ongoing Compliance:
The Regional Facilities Director was re-educated that life safety deficiencies need to be addressed immediately.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any smoke/fire damper documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director.

Monitoring:
The Regional Facilities Director will present the damper repair report and deficiencies to the EOC and Quality Committees the month following inspection and until 100% compliance is achieved for any needed repairs. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0374
Based on observation and interview the facility failed to meet requirements for smoke doors on one of six stories.

Findings include:

Based on observation on March 13, 2024 at 9:54 a.m. revealed that the fifth floor smoke door, near room 574, had a gap between the doors that exceeded one eighth of a inch.

Interview with maintenance tech on March 13, 2024 at 9:54 a.m. confirmed the smoke barrier door had a gap greater than one eighth of an inch.

Plan of Correction - To be completed: 05/30/2024

The fifth-floor smoke door near room 574 with a gap between the doors exceeding 1/8-inch will be corrected by the vendor by 5/30/24.

Ongoing Compliance:
On 4/12/24 the Regional Facilities Director created a quarterly work order requiring Facilities staff to check all smoke doors to ensure the gap between doors does not exceed 1/8-inch. An ILSM assessment is conducted by the Regional Facilities Director should deficiencies be identified that cannot be repaired within an 8-hour shift as required per Policy LS 16 Interim Life Safety Measures.

The hospital contracts with CREF whose staff is certified to conduct annual fire/smoke door inspections which includes smoke door gaps do not exceed 1/8-inch between the doors. The next survey will be conducted in May 2024. Can this be done in April at least we would be in the 30day window for Annual. Not necessary. Last inspection for SRMC was May 2023.

Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection or testing and until 100% compliance is achieved. Door survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

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 on March 12, 2024, at 1:06 p.m., revealed the most recent smoke and fire door annual inspection (conducted May 23, 2023) noted 23 door failures. The facility did not provide documentation that the door failures were repaired at the time of the survey. The facility indicated that a contractor was scheduled to repair the doors beginning on March 14, 2024.

Interview with the regional director of facilities on March 12, 2024, at 1:06 p.m., confirmed the above door repair documentation was not available at the time of the survey.

Plan of Correction - To be completed: 05/15/2024

Correction:
During the survey document review it was observed that the fire door repairs were not addressed following testing at the main campus due to vendor non-payment. There was a change in the Facilities Manager position and the door repairs were not scheduled. The vendor has been paid and contacted to commence the door repairs. Work is expected to begin by 5/15/24.

During survey, the annual fire door inspection report could not be located. Following survey, the Regional Facilities Director contacted the vendor, who provided the report dated 6/2/23. There were two failed doors identified on the report. The repairs will be completed along with the main campus repairs scheduled to begin 3/14/24.

Ongoing Compliance:
Moving forward the Regional Facilities Director/Manager will enter failed fire doors in the work order system and close them when repairs are completed to track progress. The Regional Facilities Director will escalate vendor issues to hospital Senior Leadership.

The Regional Facilities Director will file the annual fire door reports in the Fire/Life Safety documentation binder for the Cancer Center and maintain a copy on the Facilities shared drive. The Regional Facilities Director will also enter a work order to generate every May for the June testing.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any inspection documentation that does not meet regulatory requirements will be reviewed with the Facilities Director. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will review annual fire door reports and closed work orders for repairs and present to the EOC and Quality Committees until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:

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 on March 12, 2024, at 2:35 p.m., revealed the facility lacked documentation that an annual medical gas inspection was performed within the last year. The last documented inspection was completed on January 13, 2022, and there were deficiencies recorded in all three severity priorities (Urgent, High, and Low) within the report. The deficiency summary list included the following items:
1. Alarms:
A. "Nursery is required to have an area alarm for oxygen, air and vacuum." Noted as an Urgent priority.
2. Zone Valves:
A. "7 Vacuum and 1 oxygen zones are missing zone valves. Install valves with new construction." Noted as a Low priority.
B. "14 valves leaking during opening and closing of valves. Replace with new construction." Noted as a Low priority.
C. "The CVU should have its own Zone Vales for Oxygen and Vacuum." Noted as a Low priority.
D. "2 valve boxes are obstructed because they are behind an open door and require correction." Noted as a High priority.

Interview with the regional director of facilities on March 12, 2024, at 2:35 p.m., confirmed the facility lacked an updated annual medical gas inspection and documentation that verifies the above deficiencies were corrected at the time of the survey.

NFPA 101 STANDARD Electrical Systems - Receptacles:

Observations:
Name: SHARON REGIONAL HEALTH SYSTEM - Component: 02 - Tag: 0912
Based on observation and interview the facility failed to meet electrical system requirements for two of four components.

Findings include:

Based on observation on March 13, 2024 between 8:30 a.m. and 1:30 p.m. revealed that throughout component 1 and component 2 there was several receptacles within six feet of a water source not protected by a ground fault circuit interrupter.

Interview with maintenance tech on March 13, 2024 at 1:30 p.m. confirmed receptacles within six feet of a water source were not protected by a ground fault circuit interrupter.

Plan of Correction - To be completed: 05/30/2024

Upon reviewing the finding, the Regional Facilities Director identified the lack of a process to identify the need for GFCIs within 6' of a water source throughout the hospital. GFCIs will be installed at all deficient locations by 4/30/24.

Ongoing Compliance:
The Regional Facilities Director will provide education to the Facilities staff by 4/17/24 regarding the need for GFCIs to be installed within 6' of a water source. Appliances should be evaluated during the initial electrical inspection prior to use.

A full building assessment will be completed by house electricians by 5/30/24.

The Regional Facilities Director added GFCIs within 6' of a water source to the EOC rounding tool. Staff who are members of the EOC rounding team were educated prior to conducting rounds.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes checking for GFCIs in wet locations. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director EOC rounding data is a standing agenda item for the EOC and Quality Committees. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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:

Documentation review on March 13, 2024, between 1:37 p.m. and 2:50 p.m., revealed the following generator deficiencies:
A. (1:37 p.m.) the facility generator reports did not include monthly battery electrolyte-specific gravity or conductance testing;
B. (1:59 p.m.) the facility lacked documentation that an annual fuel quality was performed within the last year. The most recent documented inspection was conducted on December 22, 2022;
C. (2:50 p.m.) the annual load bank and data forms provided on the day of the survey indicated the batteries need attention;
D. (2:50 p.m.) the facility lacked documentation that a four-hour load test was completed for generator #5 and #8 at the time of the survey.

Interview with the regional director of facilities on March 13, 2024, at 2:50 p.m., confirmed the above generator deficiencies existed at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

Correction:
A. The Regional Facilities Director confirmed conductance testing was not completed on the generators. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Effective immediately, the Regional Facilities Director will ensure conductance testing is being completed on each generator and reflected on the forms accordingly. The Regional Facilities Director will review the forms for completeness prior to filing.

B. The Regional Facilities Director confirmed that annual fuel quality testing due in December 2023 is late due to vendor payment issues. The vendor has been paid and contacted to move forward with regular testing and maintenance. The annual fuel quality test is anticipated to be accomplished by 5/15/2024.

C. The Regional Facilities Director confirmed that the generator's annual load bank had battery issues that were not addressed. The Regional Director contacted the vendor on 4/15/24 to replace the generator batteries.

D. The Regional Facilities Director confirmed the late load bank testing is due to payment issues. The vendor was paid and contacted on 4/15/24 to schedule load bank testing and regular maintenance for all generators. The 4-hour load banks are anticipated to be accomplished by 5/30/24.

Ongoing Compliance:
A. The Regional Facilities Director will educate the Facilities staff who perform generator monthly testing on the requirement that monthly conductance testing must be documented. The education consisted of reviewing the form, use of the meter and documentation. All staff were trained by 4/17/24.

The Regional Facilities Director will review the monthly generator forms to confirm conductance testing is complete on all generators. Any non-compliance will result in re-education.

B. The Regional Facilities Director entered a work order for annual fuel quality testing to generate in November every year and will be closed out when testing is complete. Work orders will be generated for deficiencies to track completion. Any issues with scheduling will be escalated to hospital Senior Leadership.

C. & D. The Regional Facilities Director entered a work order for annual load bank testing for each generator a month prior to the due date; work orders will be closed out when testing is complete. Work orders will be generated for deficiencies to track completion. Any issues with scheduling will be escalated to hospital Senior Leadership.

A.-D.
Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any utility documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director.

Monitoring:
A-D
The Regional Facilities Director will present the closed work orders including any subsequent repair or follow-up issues to the EOC and Quality Committees the month following testing/repairs and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

Initial comments:Name: CANCER TREATMENT CENTER - Component: 10 - Tag: 0000

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

Based on an onsite survey that was part of a unannounced compliant investigation completed on March 12-14, 2024, it was determined that Sharon Regional Health System was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

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:

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:

1. Document review on March 13, 2024, at 1:45 p.m., revealed the following fire alarm deficiencies existed:
A. (1:45 p.m.) the facilities last documented fire alarm inspection was conducted on January 24, 2023;
B. (1:45 p.m.) the facility could not produce documentation illustrating that the semi-annual visual inspections were being completed at the time of the survey;
C. (1:45 p.m.) the facility could not produce documentation illustrating that the smoke detector sensitivity was completed at the time of the survey.

Interview with the regional director of facilities on March 13, 2024, at 1:45 p.m., confirmed the above fire alarm documentation was not on-site, at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

1 A & B: During the Cancer Center survey document review it was observed that the annual fire alarm inspection, including the semi-annual visual inspections were not completed. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. Fire alarm testing is expected to commence by 5/30/24 and is expected to continue for approximately 3 weeks. A preventive maintenance (PM) work order was entered on 4/17/24 to print annually and semi-annually the month before annual and next semi-annual testing and inspections are due so they can be scheduled to meet the requirement.

1 C: During the Cancer Center survey document review smoke detector sensitivity testing could not be produced. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. All smoke detectors sensitivity testing expected to commence by 5/30/24 with the annual fire alarm testing for the main hospital.
A preventive maintenance (PM) work order was entered on 4/17/24 to print the month before the next smoke detectors sensitivity testing is due so it can be scheduled to meet the requirement.

Ongoing Compliance:
1 A-C: Following the survey, the Regional Facilities Director reviews, approves and closes fire system testing work orders.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any semi-annual visual inspection or smoke detector sensitivity testing documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

Monitoring:
1 A-C: The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection or testing and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Facilities Director

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 on March 13, 2024, at 2:13 p.m., revealed the five-year internal valve and pipe inspection was not completed at the time of the survey.

Interview with the maintenance supervisor on March 13, 2024, at 2:13 p.m., confirmed the above inspection was not completed at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

Correction:
During the Cancer Center document review it was observed that the five-year internal valve and pipe inspection was not completed at the time of survey. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. The five-year internal valve and pipe inspection have a targeted completion date of 5/30/24.

Ongoing Compliance:
Following the survey, a preventative maintenance (PM) work order was updated to print in March 2029 to schedule the five-year internal valve and pipe inspection for April 2029.

Following the survey, the Regional Facilities Director reviews, approves and closes the five-year internal valve and pipe inspection documentation.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any five-year internal valve and pipe inspection documentation that does not meet regulatory requirements will be reviewed with the Facilities Director. The next scheduled survey is December 2024.
Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection or testing and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.
Responsible Person:
Regional Director of Facilities

NFPA 101 STANDARD Portable Fire Extinguishers:

Observations:
Name: CANCER TREATMENT CENTER - Component: 10 - Tag: 0355

Based on document review and interview, it was determined that the facility failed to remain in compliance with annual fire extinguisher inspections, affecting the entire facility.

Findings include:

Observation on March 13, 2024, at 2:36 p.m., revealed the facility lacked documentation that an annual fire extinguisher inspection was performed within the last year.

Interview with the regional director of facilities on March 13, 2024, at 2:36 a.m., confirmed the above portable fire extinguisher inspection documentation was not on-site at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

Correction:
During the Cancer Center document review it was observed that the annual fire extinguisher inspection had not occurred within the past year. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. The annual fire extinguisher testing has a target completion date of 5/30/24.

Ongoing Compliance:
Following the survey, a preventative maintenance (PM) work order was updated to print in March each year to schedule the annual fire extinguisher inspection for April.

Following the survey, the Regional Facilities Director reviews, approves and closes the annual fire extinguisher inspection documentation.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any annual fire extinguisher inspection documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.
Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.
Responsible Person:
Regional Director of Facilities

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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:

1. Observation on March 13, 2024, at 1:40 p.m., revealed the lobby area had missing ceiling tiles that allow the passage of smoke. In the event of an emergency, it could possibly delay the activation of the smoke detector.

Interview with the maintenance tech on March 13, 2024, at 1:40 p.m., confirmed the lobby area was missing ceiling tiles.

2. Document review on March 13, 2024, at 1:30 p.m., revealed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Interview with the regional director of facilities on March 13, 2024, at 1:30 p.m., confirmed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Plan of Correction - To be completed: 05/30/2024

1. All missing ceiling tiles identified at the Cancer Center during the survey were replaced on 4/15/24.

2. During the Cancer Center survey document review, the Regional Facilities Director could not provide documentation of smoke/fire damper testing. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. The testing has a target completion date of 5/30/24. A preventive maintenance (PM) work order was entered on 4/17/24 to print the month before the fire/smoke damper testing is due so it can be scheduled to meet the requirement.

Ongoing Compliance:
1. Open for Business (OFB) rounds are conducted weekly by Department Managers/designee. The inspection of missing ceiling tiles resulting in the disruption of the ceiling membrane is included on the rounding tool. Deficiencies are corrected immediately, or a corrective work order is issued.

The Regional Facilities Director reviewed the EOC rounding tool and missing ceiling tiles is on the tool.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes checking that ceiling tiles are not missing. A full report is provided to the Regional Facilities Director and deficiencies are corrected by Facilities staff or an outside vendor, if necessary. The next scheduled survey is December 2024.

2: Following the survey, the Regional Facilities Director reviews, approves and closes fire system testing work orders.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any semi-annual visual inspection or smoke detector sensitivity testing documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.
Monitoring:
1 & 2: The Regional Facilities Director will present OFB and EOC rounding data and the damper report to the EOC and Quality Committees the month following inspection and until 100% compliance is achieved. The mock survey report is presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.
Responsible Person:
Regional Director of Facilities

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Observations:
Name: CANCER TREATMENT CENTER - Component: 10 - Tag: 0761

Based on document review and interview, the facility failed to maintain, inspect, and test fire doors in accordance with regulations affecting the entire building component.

Findings include:

Document review on March 13, 2024, at 2:05 p. m., revealed the facility lacked documentation to indicate that an annual fire door inspection was performed throughout the cancer center.

Interview with the regional director of facilities on March 13, 2024, at 2:05 p. m., confirmed the above fire door inspection was not on-site during the time of the survey.

Plan of Correction - To be completed: 05/15/2024

During the Cancer Center survey of documents, the annual fire door inspection report could not be located for the surveyor. Following survey, the Regional Facilities Director contacted the fire door testing vendor, who provided the report dated 6/2/23. There were two failed doors identified on the report. The vendor has been contacted to commence with the door inspection with a target date of 5/15/24.

Ongoing Compliance:
The Regional Facilities Director will review and approve and file the annual fire door reports in the Fire/Life Safety documentation binder for the Cancer Center and maintain a copy on the Facilities shared drive. The Regional Facilities Director will also enter a work order to generate every May for the June testing.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. The next scheduled survey is December 2024.
Monitoring:
The Regional Facilities Director will present the approved annual fire door report and present it to the EOC and Quality Committees until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.
Responsible Person:
Regional Facilities Director

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 six of six emergency generators.

Findings include:

Documentation review on March 13, 2024, between 2:20 p.m. and 2:26 p.m., revealed the following generator deficiencies:
A. (2:20 p.m.) the facility lacked documentation to illustrate that weekly visual inspections were being completed. The facility communicated that they only complete monthly visual checks for generator #6 (components 10 and 11).
B. (2:22 p.m.) the facility generator reports did not include monthly battery electrolyte-specific gravity or conductance testing;
C. (2:24 p.m.) the facility lacked documentation that an annual fuel quality was performed within the last year. The most recent documented inspection was conducted on December 22, 2022;
D. (2:26 p.m.) the annual load bank and data forms provided on the day of the survey indicated the batteries need attention;

Interview with the regional director of facilities on March 13, 2024, at 2:26 p.m., confirmed the above generator deficiencies existed at the time of the survey.

Plan of Correction - To be completed: 05/15/2024

A. The Regional Facilities Director confirmed that weekly visual generator inspections were not being conducted. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Moving forward, the Regional Facilities Director will review the weekly forms for completeness and train the new Manager on the requirement and procedure to review the forms prior to filing.

B. The Regional Facilities Director confirmed conductance testing was not completed on the generator. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Moving forward, the Regional Facilities Director will review the form for completeness and train the new Manager on the requirement and procedure to review the form prior to filing.

C. The Regional Facilities Director confirmed that annual fuel quality testing due in December 2023, is late due to a change in the generator maintenance vendor due to non-payment resulting in a scheduling delay. The annual fuel quality test has a target completion date of 5/15/24. The result report is expected approximately two weeks after the test.

D. The Regional Facilities Director confirmed that the last annual load bank report had battery issues that were not addressed. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. The batteries issues have a targeted date of 5/30/24 to be addressed.

Ongoing Compliance:

A. The Regional Facilities Director will educate the Facilities staff who perform generator weekly visual inspections on the requirement that inspections must be consistently documented. The education consisted of reviewing the weekly inspection form listing the required elements. All staff will be trained on 4/17/24.

B. The Regional Facilities Director will educate the Facilities staff who perform generator monthly testing on the requirement that monthly conductance testing must be documented. The education consisted of reviewing the form, use of the meter and documentation. All staff will be trained on 4/17/24.

A & B: The Regional Facilities Director will review the weekly and monthly generator forms to confirm weekly visual inspections and monthly conductance testing is complete on all generators. Any non-compliance will result in re-education.

C. The Regional Facilities Director entered a work order for annual fuel quality testing to generate in November every year and will be closed out when testing is complete. Work orders will be generated for deficiencies to track completion. Any issues with scheduling will be escalated to hospital Senior Leadership.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any utility documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

D. The Regional Facilities Director entered a preventative maintenance (PM) work order for annual load bank testing for each generator a month prior to the due date and corrective maintenance work orders will be generated for deficiencies to track completion. Any issues with scheduling repairs will be escalated to hospital Senior Leadership.
Monitoring:
A-D: The Regional Facilities Director will present approved generator inspections, testing and maintenance work orders and reports including any subsequent repair or follow-up issues to the EOC and Quality Committees the month following testing/repairs and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.
Responsible Person:
Regional Director Facilities

Initial comments:Name: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0000

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

Based on an onsite survey that was part of a unannounced compliant investigation completed on March 12-14, 2024, it was determined that Sharon Regional Health System was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Discharge from Exits:

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0271
Based on observation and interview, the facility failed to meet exit discharge requirements for one of over two exits.

Findings include:

Observation on March 13, 2024, at 1:40 p.m., revealed the facility did not have a hard-packed, all-weather service near the therapy emergency exit. The grass service becomes soft during inclement weather and could slow down egress in an emergency. Much rain or snow accumulation could delay patients that are expected to exit or be evacuated using wheelchairs. There are bushes obstructing the access to the public way.

Interview with the maintenance tech on March 13, 2024, at 1:40 p.m., confirmed the surface is not a hard packed surface and exiting could be difficult.

Plan of Correction - To be completed: 05/30/2024

The Regional Facilities Director evaluated all other exit discharges to ensure they have a hard packed, all-weather surface and there are no obstructions in the pathway. None were found.

On 4/14/24, the bushes obstructing the access to the public way were cut back. The facility grounds maintenance team was notified on 4/12/24 to add this exit discharge/bushes to the regular landscaping maintenance. At that same time a plan was enacted to address the addition of a hard packed all weather surface near the therapy emergency exit. The installation of a hard packed surface will be completed by 5/30/24.

Ongoing Compliance:
The Regional Facilities Director entered a monthly work order for Facilities staff to inspect the grounds, including all exit discharges to ensure paths are clear. Non-compliance will result in an automatic corrective maintenance work order that will be closed when remediation is complete.

Monitoring:
The Regional Facilities Director will review and approve the closed grounds inspection work orders and present to the EOC and Quality Committees for 3 consecutive months or until 100% compliance is achieved. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1

Observations:
Name: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0291

Based on document review and interview, it was determined the facility failed to ensure emergency lighting was tested annually, affecting the entire facility.

Findings include:

Document review on March 13, 2024, at 2:32 p.m., revealed the facility could not produce documentation showing a 90-minute annual test was performed over the past 12 months for their emergency lighting.

Interview with the regional director of facilities on March 13, 2024, at 2:32 p.m., confirmed the above documentation was not available at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

The annual emergency light testing has a target completion date of 5/30/24.

Ongoing Compliance:
The Regional Facilities Director educated the Facilities staff responsible for the 90-minute annual test on the requirement that it needs to be completed on time and any barriers to completion should be immediately escalated to the Director.

The Regional Facilities Director entered a work order for the testing to be completed annually.

Monitoring:
The Regional Facilities Director will review and approve the closed annual 90-minute preventative maintenance work order and present it to the EOC and Quality Committees the month after completion. Any deficiencies will be reported until 100% of the devices have been repaired. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Person Responsible:
Regional Director Facilities

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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:

1. Document review on March 13, 2024, at 1:45 p.m., revealed the following fire alarm deficiencies existed:
A. (1:45 p.m.) the facilities last documented fire alarm inspection was conducted on January 24, 2023;
B. (1:45 p.m.) the facility could not produce documentation illustrating that the semi-annual visual inspections were being completed at the time of the survey;
C. (1:45 p.m.) the facility could not produce documentation illustrating that the smoke detector sensitivity was completed at the time of the survey.

Interview with the regional director of facilities on March 13, 2024, at 1:45 p.m., confirmed the above fire alarm documentation was not on-site, at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

Correction:
1 A & B: During the Cancer Center Building 11 survey document review it was observed that the annual fire alarm inspection, including the semi-annual visual inspections were not completed. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. Fire alarm testing has a target commencement date of 5/30/24 and is expected to continue for approximately 3 weeks. A preventive maintenance (PM) work order was entered on 4/17/24 to print annually and semi-annually the month before annual and next semi-annual testing and inspections are due so they can be scheduled to meet the requirement.

1 C: During the Cancer Center survey document review smoke detector sensitivity testing could not be produced. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. All smoke detectors sensitivity testing has a targeted commencement date of 5/30/24.

A preventive maintenance (PM) work order was entered on 4/17/24 to print the month before the next smoke detectors sensitivity testing is due so it can be scheduled to meet the requirement.

Ongoing Compliance:
1 A-C: Following the survey, the Regional Facilities Director reviews, approves and closes fire system testing work orders.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any semi-annual visual inspection or smoke detector sensitivity testing documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

Monitoring:
1 A-C: The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection or testing and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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 on March 13, 2024, at 2:13 p.m., revealed the five-year internal valve and pipe inspection was not completed at the time of the survey.

Interview with the maintenance supervisor on March 13, 2024, at 2:13 p.m., confirmed the above inspection was not completed at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

Correction:
During the Cancer Center document review it was observed that the five-year internal valve and pipe inspection was not completed at the time of survey. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. The five-year internal valve and pipe inspection have a targeted completion date of 5/30/24.

Ongoing Compliance:
Following the survey, a preventative maintenance (PM) work order was updated to print in March 2029 to schedule the five-year internal valve and pipe inspection for April 2029.

Following the survey, the Regional Facilities Director reviews, approves and closes the five-year internal valve and pipe inspection documentation.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any five-year internal valve and pipe inspection documentation that does not meet regulatory requirements will be reviewed with the Facilities Director. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection or testing and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Portable Fire Extinguishers:

Observations:
Name: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0355

Based on document review and interview, it was determined that the facility failed to remain in compliance with annual fire extinguisher inspections, affecting the entire facility.

Findings include:

Observation on March 13, 2024, at 2:36 p.m., revealed the facility lacked documentation that an annual fire extinguisher inspection was performed within the last year.

Interview with the regional director of facilities on March 13, 2024, at 2:36 a.m., confirmed the above portable fire extinguisher inspection documentation was not on-site at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

During the Cancer Center Building 11 document review it was observed that the annual fire extinguisher inspection had not occurred within the past year. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. The annual fire extinguisher testing has a target completion date of 5/30/24.

Ongoing Compliance:
Following the survey, a preventative maintenance (PM) work order was updated to print in March each year to schedule the annual fire extinguisher inspection for April.

Following the survey, the Regional Facilities Director reviews, approves and closes the annual fire extinguisher inspection documentation.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any annual fire extinguisher inspection documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will review and approve the work orders and present to the EOC and Quality Committees the month following inspection and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations. Preventative and corrective maintenance work order completion rates are a standing agenda item at the EOC Committee meetings.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Observations:
Name: CANCER TREATMENT B SIDE - Component: 11 - 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.

Document review on March 13, 2024, at 1:30 p.m., revealed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Interview with the regional director of facilities on March 13, 2024, at 1:30 p.m., confirmed the facility lacked documentation verifying the fire and smoke dampers were exercised and tested within the previous six years.

Plan of Correction - To be completed: 05/30/2024

During the Cancer Center Building 11 survey document review, the Regional Facilities Director could not provide documentation of smoke/fire damper testing. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay The testing has a target completion date of 5/30/24. A preventive maintenance (PM) work order was entered on 4/17/24 to print the month before the fire/smoke damper testing is due so it can be scheduled to meet the requirement.

Ongoing Compliance:
Following the survey, the Regional Facilities Director reviews, approves and closes fire system testing work orders.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any semi-annual visual inspection or smoke detector sensitivity testing documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will present the damper report to the EOC and Quality Committees the month following inspection and any repairs until 100% of dampers are repaired. The mock survey report is presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Observations:
Name: CANCER TREATMENT B SIDE - Component: 11 - Tag: 0761
Based on document review and interview, the facility failed to maintain, inspect, and test fire doors in accordance with regulations affecting the entire building component.

Findings include:

Document review on March 13, 2024, at 2:05 p. m., revealed the facility lacked documentation to indicate that an annual fire door inspection was performed throughout the cancer center building.

Interview with the regional director of facilities on March 13, 2024, at 2:05 p. m., confirmed the above fire door inspection was not on-site during the time of the survey.

Plan of Correction - To be completed: 05/15/2024

During the Cancer Center Building 11 survey of documents, the annual fire door inspection report could not be located for the surveyor. Following survey, the Regional Facilities Director contacted the fire door testing vendor, who provided the report dated 6/2/23. There were two failed doors identified on the report. The vendor has been contacted to commence with the door inspections with a target date of 5/15/24.

Ongoing Compliance:
The Regional Facilities Director will review and approve and file the annual fire door reports in the Fire/Life Safety documentation binder for the Cancer Center and maintain a copy on the Facilities shared drive. The Regional Facilities Director will also enter a work order to generate every May for the June testing.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. The next scheduled survey is December 2024.

Monitoring:
The Regional Facilities Director will present the approved annual fire door report and present it to the EOC and Quality Committees until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

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 six of six emergency generators.

Findings include:

Documentation review on March 13, 2024, between 2:20 p.m. and 2:26 p.m., revealed the following generator deficiencies:
A. (2:20 p.m.) the facility lacked documentation to illustrate that weekly visual inspections were being completed. The facility communicated that they only complete monthly visual checks for generator #6 (components 10 and 11).
B. (2:22 p.m.) the facility generator reports did not include monthly battery electrolyte-specific gravity or conductance testing;
C. (2:24 p.m.) the facility lacked documentation that an annual fuel quality was performed within the last year. The most recent documented inspection was conducted on December 22, 2022;
D. (2:26 p.m.) the annual load bank and data forms provided on the day of the survey indicated the batteries need attention;

Interview with the regional director of facilities on March 13, 2024, at 2:26 p.m., confirmed the above generator deficiencies existed at the time of the survey.

Plan of Correction - To be completed: 05/30/2024

A. During document review for Cancer Center Building 11, the Regional Facilities Director confirmed that weekly visual generator inspections were not being conducted. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Moving forward, the Regional Facilities Director will review the weekly forms for completeness and train the new Manager on the requirement and procedure to review the forms prior to filing.

B. The Regional Facilities Director confirmed conductance testing was not completed on the generator. The process for reviewing monthly generator test forms broke down when the Facilities Manager left the position. Moving forward, the Regional Facilities Director will review the form for completeness and train the new Manager on the requirement and procedure to review the form prior to filing.

C. The Regional Facilities Director confirmed that annual fuel quality testing due in December 2023, is late due to a change in the generator maintenance vendor due to non-payment resulting in a scheduling delay. The annual fuel quality test has a target completion date of 5/15/24. The result report is expected approximately two weeks after the test.

D. The Regional Facilities Director confirmed that the last annual load bank report had battery issues that were not addressed. There was a change in the fire alarm system vendor due to non-payment resulting in a scheduling delay. The batteries issues have a targeted date of 5/30/24 to be addressed.

Ongoing Compliance:

A. The Regional Facilities Director will educate the Facilities staff who perform generator weekly visual inspections on the requirement that inspections must be consistently documented. The education consisted of reviewing the weekly inspection form listing the required elements. All staff will be trained on 4/17/24.

B. The Regional Facilities Director will educate the Facilities staff who perform generator monthly testing on the requirement that monthly conductance testing must be documented. The education consisted of reviewing the form, use of the meter and documentation. All staff will be trained on 4/17/24.

A & B: The Regional Facilities Director will review the weekly and monthly generator forms to confirm weekly visual inspections and monthly conductance testing is complete on all generators. Any non-compliance will result in re-education.

C. The Regional Facilities Director entered a work order for annual fuel quality testing to generate in November every year and will be closed out when testing is complete. Work orders will be generated for deficiencies to track completion. Any issues with scheduling will be escalated to hospital Senior Leadership.

Corporate Real Estate & Facilities (CREF) EH&S team conducts an annual environment of care/life safety mock survey that includes a document review assessment. Any utility documentation that does not meet regulatory requirements will be reviewed with the Regional Facilities Director. The next scheduled survey is December 2024.

D. The Regional Facilities Director entered a preventative maintenance (PM) work order for annual load bank testing for each generator a month prior to the due date and corrective maintenance work orders will be generated for deficiencies to track completion. Any issues with scheduling repairs will be escalated to hospital Senior Leadership.

Monitoring:
1 A-D: The Regional Facilities Director will present approved generator inspections, testing and maintenance work orders and reports including any subsequent repair or follow-up issues to the EOC and Quality Committees the month following testing/repairs and until 100% compliance is achieved. Mock survey results are presented the month following receipt of the report. Senior Leadership are active members of these committees. Meeting minutes are forwarded to the BOD for review and recommendations.

Responsible Person:
Regional Director Facilities

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