QA Investigation Results

Pennsylvania Department of Health
BARNES-KASSON COUNTY HOSPITAL
Building Inspection Results

BARNES-KASSON COUNTY HOSPITAL
Building Inspection Results For:


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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on April 30, 2024, at Barnes-Kasson County Hospital, it was determined there were no deficiencies identified with the requirements of 42 CFR 485.625.




Plan of Correction:




Initial Comments:
Name - MAIN BUILDING Component - 01

Facility ID# 02050101
Component 01
Main Building

Based on an unannounced Medicare Recertification Survey completed on April 30, 2024, it was determined that Barnes-Kasson County Hospital was not in compliance with the requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 485.623(d).

This is a three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.




Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - MAIN BUILDING Component - 01
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:

Based on observation and interview, it was determined the facility exceeded maximum allowable story height for this type of construction.

Findings include:

1. Observation on April 30, 2024, at 10:45 am, revealed the facility exceeded the maximum allowable story height for a three story, Type II (000), unprotected, noncombustible building.

Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the facility exceeds maximum allowable story height for this type of construction.







Plan of Correction:

The facility finds the POC acceptable per FSES plan of care correction. FSES on file with date of 04/17/2018.


NFPA 101 STANDARD
Stairways and Smokeproof Enclosures

Name - MAIN BUILDING Component - 01
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:

Based on observation and interview, it was determined the facility failed to maintain the required fire rating of stair tower doors on one of three floors.

Findings include:

1. Observation on April 30, 2024, at 12;14 pm, revealed the stair tower door at the E.R. failed to latch in the corresponding frame when tested.

Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the lacked positive latching.






Plan of Correction:

The facility will adjust/repair the stair tower door at the E.R. so that the door will latch in the corresponding frame.

A facility wide assessment will be conducted to make sure that all stair tower doors latch in the corresponding frame. Barnes Kasson will make any corrections identified during the assessment.

The facility manager will be responsible for continued compliance with this plan of correction.



NFPA 101 STANDARD
Hazardous Areas - Enclosure

Name - MAIN BUILDING Component - 01
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas on one of three floors.

Findings include:

1. Observation on April 30, 2024, at 12:11 pm, revealed the door to the mechanical room failed to latch in the frame when tested.

Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the door lacked positive latching.






Plan of Correction:

The facility will adjust/repair the door to the mechanical room so that the door will latch in the frame.

A facility wide assessment of doors to hazardous areas to ensure that all doors to hazardous areas latch in the frame. Barnes Kasson will make any corrections identified during the assessment.

The facility manager will be responsible for continued compliance with this plan of correction.



NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie

Name - MAIN BUILDING Component - 01
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:

Based on observation and interview, it was determined the facility failed to maintain the required fire resistance of smoke barrier walls in one location affecting two of four smoke compartments.

Findings include:

1. Observation on April 30, 2024, at 11:53 am, revealed an unsealed cable penetration of the 2nd floor smoke barrier wall in room 209.

Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the wiring penetration was not sealed.








Plan of Correction:

The unsealed penetration of the 2nd floor smoke barrier wall in room 209 will be sealed with fire rated material.

A facility wide assessment will be conducted to ensure all smoke barrier walls are maintained in a fire resistant state, with no penetrations. Barnes Kasson will make any corrections identified during the assessment.

The facility manager will be responsible for continued compliance with this plan of correction.



NFPA 101 STANDARD
Gas and Vacuum Piped Systems - Inspection and

Name - MAIN BUILDING Component - 01
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:

Based on observation and interview, it was determined the facility failed to maintain the piped-in medical gas system in one of four smoke compartments.

Findings include:

1. Observation on April 30, 2024, at 12:02 pm, revealed the medical gas lines were in contact with galvanized conduit and MC cables in several locations above the ceiling outside the O.R. on the 2nd floor.

Exit interview with facility maintenance supervisor, on April 30, 2024 at 1:00 pm, confirmed the copper medical gas lines were in contact with dissimilar metals.







Plan of Correction:

The facility will repair the medical gas line brackets so that the line is not in contact with the galvanized conduit and MC cables in the ceiling outside the O.R. on the 2nd floor.

A facility wide assessment will be conducted to make sure that all piped-in medical gas systems are maintained appropriately. Barnes Kasson will make any corrections identified during this facility wide assessment.

The facility manager will be responsible for continued compliance with this plan of correction.