Pennsylvania Department of Health
EVANGELICAL COMMUNITY HOSPITAL
Building Inspection Results

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EVANGELICAL COMMUNITY HOSPITAL
Inspection Results For:

There are  108 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
EVANGELICAL COMMUNITY HOSPITAL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID# 570201
Component 01
Main Building

Based on a Relicensure Survey completed on January 29, 2024, it was determined that Evangelical Community Hospital was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a three story, Type II (222), fire resistive building, with a basement, and rooftop mechanical spaces, that is fully sprinklered.





 Plan of Correction:


NFPA 101 STANDARD Building Construction Type and Height:State only Deficiency.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in multiple locations, affecting two of four floors.

Findings include:

1. Observation on January 29, 2024, between 12:20 p.m., and 12:50 p.m., revealed the following:

a. 12:20 p.m.,-12:40 p.m., unprotected structural steel and combustible 2 x 4 s, located within second floor "pod" restrooms.
b. 12:40 p.m.,-12:50 p.m., combustible, paper-backed, insulating materials and combustible 2 x 4 s, located within third floor, "pod" restrooms.

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the building construction deficiencies.




 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) will employ an engineering and design company to investigate, design, and submit drawings to the Department of Health plan review for approval to address the unprotected structural steel, combustible 2"x4" s, and paperbacked insulation. Upon receipt of the approved plans and project number, ECH will obtain bids from contractors, select a contractor, order required materials, and complete the work per the approved drawings.

b) Corrections will be completed by December 31, 2024.

c) Corrections will be tracked via a construction log and photos.

d) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:State only Deficiency.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain one stair tower enclosure, affecting one of four floors.

Findings include:

1. Observation on January 29, 2024, at 10:41 a.m., revealed the second floor portion of the SM stair tower enclosure lacked a vestibule between stair tower and the CSR Suite storage area.

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the stair tower enclosure deficiency.




 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) will employ an engineering and design company to investigate, design, and submit drawings to the Department of Health plan review for approval to create a vestibule. Upon receipt of the approved plans and project number, ECH will obtain bids from contractors, select a contractor, order required materials including correctly rated doors and frames to create the vestibule per the approved drawings.

b) Corrections will be completed by December 31, 2024.

c) Corrections will be tracked via a construction log and photos.

d) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.

NFPA 101 STANDARD Spinkler System - Installation:State only Deficiency.
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0351

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of four floors.

Findings include:

1. Observation on January 29, 2024, at 11:03 a.m., revealed the second floor portion of the SH stair tower enclosure lacked automatic sprinkler protection at the landing area.

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the automatic sprinkler system deficiency.




 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) will work with a sprinkler contractor to install the appropriate sprinkler coverage at the stair landing. The new location will be documented on the as-built drawings.

b) Corrections will be completed by April 30th, 2024.

c) All corrections will be tracked with a corrective work order and photographs.

d) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.

NFPA 101 STANDARD Corridor - Doors:State only Deficiency.
Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor openings in five locations, affecting two of four floors.

Findings include:

1. Observation on January 29, 2024, between 9:02 a.m., and 10:32 a.m., revealed the following:

a. 9:02 a.m., the Room 3310 door was not smoke-tight.
b. 9:05 a.m., the Room 3317 door was not smoke-tight.
c. 9:22 a.m., the Room 3405 door was not smoke-tight.
d. 10:26 a.m., the Room S2511 door was mot smoke-tight.
e. 10:32 a.m., the Room S2518 door was not smoke-tight.

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the corridor opening deficiencies.




 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) Plant Engineering staff will adjust and repair door closure to ensure positive latching.

b) This repair will occur by April 30th, 2024.

c) All corrections within the report will be tracked with the corrective work orders and photographs.

d) All smoke and fire doors are on a preventative maintenance work order issued on an annual basis, for inspection. Brand Services will perform annual smoke and fire door inspections. All door deficiency reports will generate corrective work orders, through our CMMS system.

e) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:State only Deficiency.
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: MAIN BUILDING - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall, affecting one of four floors.

Findings include:

1. Observation on January 29, 2024, at 9:40 a.m., revealed exposed metal studding, at the top of the portion of the smoke barrier wall, located within 3331A.

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the smoke barrier separation wall deficiency.





 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) Plant Engineering staff will install 5/8" gypsum board to the exposed metal studding to establish the one-hour smoke barrier wall.

b) This repair will occur by April 30th, 2024.

c) All corrections within the report will be tracked with the corrective work orders and photographs.

d) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:State only Deficiency.
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: MAIN BUILDING - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in three locations, affecting two of four floors.

Findings include:

1. Observation on January 29, 2024, between 9:20 a.m., and 10:37 a.m., revealed the following smoke barrier separation doors required adjustment to fully latch:

a. 9:20 a.m., third floor, located closest to PR-4.
b. 9:50 a.m., third floor, M3416.
c. 10:37 a.m., second floor, M2416.

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the smoke barrier separation door deficiencies.




 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) Plant Engineering staff will adjust and repair door closure to ensure positive latching.

b) This repair will occur by April 30, 2024.

c) All corrections within the report will be tracked with the corrective work orders and photographs.

d) All smoke and fire doors are on a preventative maintenance work order issued on an annual basis, for inspection. Brand Services will perform annual smoke and fire door inspections. All door deficiency reports will generate corrective work orders, through our CMMS system.

e) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:State only Deficiency.
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0541

Based on observation and interview, it was determined the facility failed to maintain one soiled linen chute, affecting one of four floors.

Findings include:

1. Observation on January 29, 2024, at 9:38 a.m., revealed a single layer of 5/8" gypsum board sealed the third floor (top) portion of the four story, vertical opening (less than the required, two-hour, fire resistive integrity).

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the soiled linen chute deficiency.





 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) Plant Engineering staff will install a second layer of 5/8" gypsum board to the vertical opening to establish the required two-hour rating.

b) This repair will occur by April 30th, 2024.

c) All corrections within the report will be tracked with the corrective work orders and photographs.

d) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.

Initial comments:Name: NEW PATIENT TOWER - Component: 02 - Tag: 0000


Facility ID# 570201
Component 02
New Patient Tower

Based on a Relicensure Survey completed on January 29, 2024, it was determined that Evangelical Community Hospital was not in compliance with the following requirements of the Life Safety Code for new health care occupancy.

This is a four story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Subdivision of Building Space - Smoke Barrier:State only Deficiency.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 NEW
Doors in smoke barriers have at least a 20 minute fire protection rating or are at least 1-3/4 inch thick solid bonded core wood.
Required clear widths are provided per 18.3.7.6(4) and (5).
Nonrated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal-sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction.
Doors shall be self-closing and rabbets, bevels, or astragals are required at the meeting edges. Positive latching is not required.
18.3.7.6, 18.3.7.7, 18.3.7.8
Observations:
Name: NEW PATIENT TOWER - Component: 02 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors, on two of five floors.

Findings include:

1. Observation on January 29, 2024, at 1:30 p.m., revealed the fourth floor, P4633 smoke barrier separation doors required adjustment to fully latch.

2. Observation on January 29, 2024, at 1:47 p.m., revealed the first floor, P1625 smoke barrier separation doors required adjustment to fully latch.

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the smoke barrier separation door deficiency.




 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) staff will adjust and repair door closure to ensure positive latching.

b) This repair will occur by 3/29/2024.

c) All corrections within the report will be tracked with the corrective work orders and photographs.

d) All smoke and fire doors are on a preventative maintenance work order issued on an annual basis, for inspection. Brand Services will perform annual smoke and fire door inspections. All door deficiency reports will generate corrective work orders, through our CMMS system.

e) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.

Initial comments:Name: BUILDING 02 - Component: 12 - Tag: 0000


Facility ID# 570201
Component 12
South Building

Based on a Relicensure Survey completed on January 29, 2024, it was determined that Evangelical Community Hospital 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 (222), fire resistive building, with a basement, that is fully sprinklered.






 Plan of Correction:


NFPA 101 STANDARD Electrical Equipment - Other:State only Deficiency.
Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 10 (NFPA 99)
Observations:
Name: BUILDING 02 - Component: 12 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain the electrical system in one locations, affecting one of two floors.

Findings include:

1. Observation on January 29, 2024, at 12:45 p.m., revealed a junction box lacked a cover plate, located within the basement Mechanical Room 0506.

Exit interview on January 29, 2024, between 2:15 p.m., and 2:30 p.m., with the Facilities Manager, confirmed the electrical system deficiency.








 Plan of Correction - To be completed: 02/16/2024

a) Evangelical Community Hospital (ECH) staff will install the correct type & size cover plate on the junction box.

b) This repair will occur by 3/29/24.

c) All corrections within the report will be tracked with the corrective work orders and photographs.

d) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.


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