QA Investigation Results

Pennsylvania Department of Health
CROZER-CHESTER MEDICAL CENTER
Building Inspection Results

CROZER-CHESTER MEDICAL CENTER
Building Inspection Results For:


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Initial Comments:
Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01

Facility ID #037201
Component 01
Main Building (North, South, West, Central and Outpatient Care Pavilion (ACP)

Based on a Relicensure Survey conducted on December 5 - 8, 2022, it was determined that Crozer-Chester Medical Center Upland - Main Building (North, South, West, Central and Outpatient Care Pavilion (ACP), were not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy.

This is a six story, Type II (000), unprotected non-combustible construction, which is fully sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Multiple Occupancies

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:
* They are not intended to serve four or more inpatients.
* They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
* The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of common wall separations, affecting two of six floors.

Findings include:

1. Observations on December 6, 2022, revealed fire rated common wall deficiencies in the following locations:

a. 10:30 am, ground floor above the doors to MRI Suite, unsealed penetration around data wires.
b. 11:50 am, ground floor above the doors to pathology, penetration around data conduit.
c. 12:30 pm, ground floor above new ED doors at CT scan, Unsealed penetration around data wires.
d. 12:45 pm, basement main distribution room, above fire doors to ED basement, around data conduit.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the common wall deficiencies.






Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Building Construction Type and Height

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) 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, documentation review and interview, it was determined the facility failed to maintain the building construction requirements and to ensure the structural members were protected by fire resistive rated construction throughout the facility.

Findings Include:

1. Observation, documentation review, and interview on December 6, 2022, between 8:30 am and 1:00 pm, revealed that structural steel members lack fire resistive protection in various locations throughout the building.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the missing fire resistive protection.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Means of Egress - General

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:

Based on observation and interview, it was determined the facility failed to ensure exit doors did not require excessive force to open, affecting one of six levels within the component.

Findings Include:

1. Observation on December 6, 2022, at 12:00 pm, revealed the ground floor GP-02 exit door required excessive force to open. Refer to NFPA 101, Section 7.2.4.5

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the egress door required excessive force to open.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Egress Doors

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4


Observations:

Based on observation and interview, it was determined the facility failed to maintain delayed-egress doors, affecting one of six floors in the facility.

Findings include:

1. Observation on December 6, 2022, at 12:50 pm, revealed, on the 3rd floor, the Stair #9 delayed egress door failed to open after 15 seconds.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the delayed egress door failed to open.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Stairways and Smokeproof Enclosures

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) 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 fire resistance rating of stair towers, affecting one of six levels in this component.

Findings include:

1. Observation on December 6, 2022, between 10:35 am and 12:55 pm, revealed following stair tower deficiencies:

a. 10:35 am, ground floor, stair 9, unsealed 2-inch hole above the door;
d. 12:55 pm, ground floor, stair tower #2, door failed to close and latch.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the stair tower deficiencies.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Number of Exits - Story and Compartment

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:

Based upon observation, documentation review, and interview, it was determined the facility failed to maintain two remote exits, affecting one of six floors within this component.

Findings include:

1. Observation on December 6, 2022, at 10:00 am, revealed on the fourth floor, exiting from the Out Patient Care Pavilion or (ACP), the path of egress leads through an intervening recovery room/outpatient waiting room located within the Main Center Wing.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the lack of a second acceptable exit.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
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:

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system, affecting three of six floors within the facility.

Findings include:

1. Observations on December 6, 2022 and December 7, 2022, revealed blocked pull stations in the the following locations:

December 6, 2022
a. 11:20 am, 4th floor, Stair Tower #10;
b. 11:36 am, 4th floor, Operating Room;
c. 11:45 am, 5th floor, IT Room entrance.

December 7, 2022
a. 10:49 am, 2nd floor, Stair Tower #1;
b. 11:00 am, 2nd floor, Stair Tower #10;
c. 1:00 pm, 1st floor, by room 1515.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the blocked pulol stations.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Portable Fire Extinguishers

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
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:

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers, affecting one of six floors in the facility.

Findings include:

1. Observation on December 6, 2022, at 11:45 am, revealed, on the fifth floor, a fire extinguisher was blocked at the IT Room entrance door.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the blovked fire extinguisher.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) 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 fire rating of the smoke barrier walls affecting five of six floors.

Findings include:

1. Observations on December 6, 7 and 8, 2022, revealed unsealed penetrations and openings in smoke barrier walls in the following locations:

December 6, 2022
a. 10:45 am, ground floor 5-bank elevator lobby, above north smoke doors, around data conduit.
b. 11:00 am, 4th floor, above smoke doors by 4P-01;
c. 11:10 am, 4th floor, above smoke doors at the entrance to ICU, around MC cable;
d. 12:05 pm, ground floor, above smoke doors by stair #2, around data wire bundle;
e. 12:06 pm, 3rd floor, above smoke doors to ACP, around a black cable;
f. 12:15 pm, ground floor, above smoke doors to old ER, around data wires;
g. 12:50 pm, ground floor physical medicine & rehab rear entrance, around sprinkler pipe and data wires.

December 7, 2022
a. 10:20 am, 2nd floor, above smoke doors at the entance to ACP, around data wires;
b. 1:35 pm, 1st floor, above smoke doors at the end of the Administration Hallway by the Executive Conference Room, around data wires.

December 8, 2022
a. 9:20 am, 1st floor, above smoke doors at entrance to Geri Psych, an opening.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the unsealed penetrations.


2. Observation on December 6, 2022, at 11:20 am, revealed, on the 4th floor, a linen cart blocking the smoke doors by room 4216.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the blocked smoke doors.


3. Observation on December 6, 2022, at 12:33 pm, revealed, on the 3rd floor, the smoke door by room 3410 was propped open with a door stop.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the propped open smoke door.


4. Observation on December 7, 2022, at 11:00 am, revealed, in pain management recovery area, a missing section of the smoke barrier wall above the suspended ceiling.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the incomplete smoke partition.











Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Rubbish Chutes, Incinerators, and Laundry Chu

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
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:

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of laundry chutes and laundry chute discharge rooms, affecting one of six floors.

Findings include:

1. Observation on December 6, 2022, at 11:30 am, revealed the ground floor south wing linen chute door failed to close and latch when tested.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the chute door deficiency.


2. Observation on December 6, 2022, between 11:35 am and 12:05 pm, revealed, the following laundry chute discharge room doors were obstructed from closing:

a. 11:35 am, ground floor south, chocked with a piece of wood.
b. 12:05 pm, ground floor west, chocked with wood and laundry bag pile.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the chute room door deficiencies.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Electrical Systems - Other

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 6 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to remove temporary wiring; to protect electrical wiring, affecting two of six floors within the facility.

Findings include:

1. Observation made on December 6, 2022, at 10:50 am, revealed abandoned temporary lighting above the ceiling in the SPU Waiting Room.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the abandoned temporary wiring.


2. Obervations on December 7, 2022, between 1:10 pm and 1:15 am, revealed open junction boxes in the following locations:

a. 1:10 pm, 1st floor, above the ceiling to the left of Stairwell G, near electric panel LP1-1;
b. 1:15 pm, 1st floor, above the smoke doors by the rear entrance, near Conference Rooms 3 & 4.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the open junction boxes.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Observations:

Based on observation and interview, it was determined the facility failed to install remote emergency stop switches for the emergency generators, affecting the entire facility.

Findings include:

1. Observations on December 6 - 7, 2022, revealed there were no emergency generator remote manual stop stations located outside of the generator enclosures for each of the facilities emergency generators.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed there were no remote manual stop switches located outside of the generator enclosures.






Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Electrical Equipment - Power Cords and Extens

Name - MAIN BUILDING (NORTH,SOUTH,WEST,CENTRAL,ACP) Component - 01
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:

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of six floors.

Findings include:

1. Observations on December 6 - 7, 2022, revealed the following unauthorized electrical devices:

a. 11:15 am, ground floor telecom room, microwave plugged into surge protector.
b. 11:35 am, ground floor blood bank breakroom, microwave plugged into surge protector.
c. 11:40 am, ground floor main lab instrument side, multiple extension cords powering lab equipment.
d. 11:55 am, ground floor pathology breakroom, microwave plugged into surge protector.
e. 12:00 pm, ground floor patient services breakroom, microwave plugged into surge protector.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the unauthorized electrical devices.






Plan of Correction:

An approved Plan of Correction is not on file.


Initial Comments:
Name - BUILDING 03 (MRI BUILDING) Component - 03

Facility ID #037201
Building 03
MRI Building

Based on a Relicensure Survey conducted on December 5 - 8, 2022, at Crozer Chester Medical Center, MRI Building, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing Hospital health care occupancy.

The is a one-story, Type II (222), fire resistive construction, which is fully-sprinklered.






Plan of Correction:




Initial Comments:
Name - EMERGENCY DEPARTMENT EXPANSION Component - 04

Facility ID# 037201
Component 04
Emergency Department Expansion

Based on a Relicensure Survey completed on December 5 - 8, 2022, it was determined that Crozer-Chester Medical Center - Emergency Department was not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy.

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






Plan of Correction:




NFPA 101 STANDARD
Multiple Occupancies

Name - EMERGENCY DEPARTMENT EXPANSION Component - 04
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:
* They are not intended to serve four or more inpatients.
* They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
* The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of two floors.

Findings include:

1. Observation on December 7, 2022, at 12:50 pm, revealed, on ground floor, above the doors from ED to ER, an unsealed penetration around data wires.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the unsealed penetration.






Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Hazardous Areas - Enclosure

Name - EMERGENCY DEPARTMENT EXPANSION Component - 04
Hazardous Areas - Enclosure
2012 EXISTING
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. 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

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 hazardous areas in sprinklered locations, affecting one of two floors.

Findings Include:

1. Observation on December 7, 2022, at 1:15 pm, revealed, in ground floor ED by the ambulance entrance, the soiled utility room door failed to close and positively latch.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the door.






Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Electrical Equipment - Power Cords and Extens

Name - EMERGENCY DEPARTMENT EXPANSION Component - 04
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:

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices, affecting one of two floors.

Findings include:

1. Observation on December 7, 2022, at 1:10 pm, revealed, in ground floor ED EMT Room, a microwave plugged into a surge protector.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the unauthorized electrical device.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag

Name - EMERGENCY DEPARTMENT EXPANSION Component - 04
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to provide means of securing oxygen cylinders., on one of two floors.

Findings include:

1. Observation on December 7, 2022, at 11:25 am, revealed, in 2nd floor helipad lobby, there was a freestanding "E" sized oxygen cylinder that was not in a secured holder.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the oxygen cylinder was not secured.





Plan of Correction:

An approved Plan of Correction is not on file.


Initial Comments:
Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20

Facility ID #037201
Component 20
Taylor Hospital Main Building

Based on a Relicensure Survey conducted on December 5 - 8, 2022, it was determined that Crozer Chester Medical Center Taylor Hospital was not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy.

This is a five story, Type II (222), fire resistive construction, which is fully sprinklered.






Plan of Correction:




NFPA 101 STANDARD
Multiple Occupancies

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:
* They are not intended to serve four or more inpatients.
* They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
* The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of four floors

Findings include:

1. Observation on December 5, 2022, at 10:30 am, revealed, on ground floor OR back-hall by Chester Pike exit, 1- layer of drywall was removed from the wall near the damper; compromising the integrity of the fire resistance rating.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed
the unsealed penetration.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Means of Egress - General

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:

Based on document review and interview, it was determined the facility failed to maintain means of egress free of all obstructions, affecting the entire facility.

Findings include:

1. Document reveiw on December 5, 2022, at 8:15 am, revealed the facility could not produce documementation of a snow removal policy.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the lack of documentation




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Stairways and Smokeproof Enclosures

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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 smoke resistance of stairways, affecting two of five levels in the facility.

Findings include:

1. Observation on December 5, 2022, between 10:37 am and 11:40 am, revealed the doors to stairways failed to latch in the following locations:

a. 10:37 am, 4th floor, Stair C;
b. 11:15 am, 1st floor, Stair H;
c. 11:40 am, 1st floor, Stair C.
d. 11:50 am, kitchen stairtower.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the stairway doors failed to latch.







Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Emergency Lighting

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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:

Based on document review and interview, it was determined the facility failed to maintain emergency lighting, affecting the entire component.

Findings include:

1. Document review on December 5, 2022, at 8:15 am, revealed the facilty could not produce documentation that an annual, 90-minute test of the emergency lighting was conducted.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the lack of documentation.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Cooking Facilities

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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:

Based on document review and interciew, it was determined the facility failed to maintain cooking facilities, affecting the entire component.

Findings include:

1. Document review on December 5, 2022, at 8:15 am, revealed the facility could not produce documentation that a kitchen hood supression test was completed within six months of the March 10, 2022 test.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the lack of documentation.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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:

Based on document review and interview, it was determined the facilty failed to maintain and inspect the sprinkler system, affecting the entire component.

Findings include:

1. Document review on December 5, 2022, at 8:15 am, revealed the facility could not produce documentation of the following tests and inspections:

a. Quarterly sprinkler inspections for the 3rd quarter of 2022 and 4th quarter of 2021;
b. Annual fire pump test.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the lack of documentation.


2. Observation on December 5, 2022, at 11:00 am, revealed sprinkler gauges dated 2013, exceeding the 5-year service interval, in the following locations:

a. ground floor pre-action room.
b. ground floor OR mechanical room.
c. ground floor boiler room.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the gauges were beyond the 5-year service interval.






Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Portable Fire Extinguishers

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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:

Based on document review and interview, it was determined the facility failed to maintain fire extinguishers, affecting the entire facility.

Findings include:

1. Document review on December 5, 2022, at 8:15 am, revealed the facility could not provide the following documentation:

a. Annual fire extinguisher maintenance;
b. Service certification for the fire extinguisher inspector.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the lack of documentation.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Corridor - Doors

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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:

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor doors, affecting one of five levels in the facility.

Findings include:

1. Observation on December 5, 2022, at 11:02 am, revealed, on the 3rd floor, the Medication Room across from Room 344 was missing door hardware.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the missing door hardware.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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 fire resistance of smoke barriers, affecting one of five levels in the facility.

Findings include:

1. Observation on December 5, 2022, at 10:54 am, revealed, on the 3rd floor, an open penetration by an MC cable in the smoke barrier by Room 311.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the open penetration.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Fire Drills

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Observations:

Based on document review and interview, it was determined the facility failed to properly conduct fire drills, affecting the entire component.

Findings include:

1. Document review on December 5, 2022, at 8:15 am, revealed the facility could not produce documentation that fire drills had been conducted for the months of January, February and March of 2022 as well as December of 2021.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the lack of documentation.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Electrical Systems - Other

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 6 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to ensure electrical panels were assessable and protect electrical wiring, in accordance with with NFPA 70 2011 Section 110.26, affecting two of five levels in the facility.

Findings include:

1. Observation on December 5, 2022, at 11:30 am, revealed, on the 2nd floor, the electrical panels at the Nurses' Station were blocked by trash cans.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the blocked electrical panels.


2. Observation on December 5, 2022, at 11:55 am, revealed, on the 1st floor, an unsecured junction box above the ceiling near Elevator #2.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the unsecured junction box.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Electrical Systems - Receptacles

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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), 6.3.2.4.2 (NFPA 99)

Observations:

Based on documentation review and interview it was determined the facility failed to ensure that electrical receptacles were tested in patient care rooms and at deep sedation bed locations, within the facility.

Findings include:

1. Document review on December 5, 2022, at 8:15 am, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the facility could not provide documentation that the receptacles were tested.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Electrical Equipment - Power Cords and Extens

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
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:

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting two of four levels within this component.

Findings include:

1. Observations on December 5, 2022, revealed the following unauthorized electrical devices:

a. 10:50 am, ground floor OR breakroom, fridge plugged into surge protector.
b. 10:45 am, 1st floor kitchen, multiple labeling machines plugged into a multiplier.
c. 12:00 pm, 1st floor EVS office, microwave and fridge plugged into surge protector.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed
the unauthorized electrical devices.






Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag

Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to provide means of securing oxygen cylinders, on one of three floors.

Findings include:

1. Observation on December 5, 2022, at 12:05 pm, revealed, in 1st floor central supply oxygen room, there was an "E" sized oxygen cylinder lying atop a rack of oxygen cylinders.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed
the unsecured oxygen cylinder.




Plan of Correction:

An approved Plan of Correction is not on file.


Initial Comments:
Name - BUILDING 06 (TAYLOR A BUILDING) Component - 21

Facility ID # 037201
Component 21
Taylor Hospital A Building

Based on a Relicensure Survey conducted on December 5 - 8, 2022, it was determined that Crozer Chester Medical Center Taylor Hospital A Building was not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy.

This is a three-story, Type II(222), fire-resistive construction, with a basement, which is fully sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Stairways and Smokeproof Enclosures

Name - BUILDING 06 (TAYLOR A BUILDING) Component - 21
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 smoke resistance of stairwells, affecting two of four levels in the facility.

Findings include:

1. Observation on December 5, 2022, at 9:35 am, revealed, on the 2nd floor, the doors to Stair G failed to close and latch.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the doors failed to close and latch.


2. Observation on December 5, 2022, at 9:40 am, revealed, basement stair tower A North had a cart stored in the landing.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the storage in the stair tower..






Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - BUILDING 06 (TAYLOR A BUILDING) Component - 21
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.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation review and interview, it was determined the facility failed to maintain the fire alarm system in proper operating condition, affecting the entire facility.

Findings Include:

1. Observation on December 5, 2022, at 9:50 am, revealed, in ground floor fast track lobby, the facility fire alarm panel was in trouble mode at time of survey.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed
the fire alarm panel trouble status.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - BUILDING 06 (TAYLOR A BUILDING) Component - 21
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:

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system, affecting two of four levels in the facility.

Findings include:

1. Observation on December 5, 2022, at 9:40 am, revealed, in the 2nd floor Classroom, a concealed sprinkler was missing its protective cap.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the missing protective cap for the sprinkler.


2. Observation on December 5, 2022, at 9:42 am, revealed, in the 2nd floor Office next to the Nutrition Office, a sprinkler was missing its escutcheon.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the missing sprinkler escutcheon.


3. Observation on December 6, 2022, at 9:45 am, revealed, in the 2nd floor IT room, a missing ceiling tile which could delay the activation of the sprinkler.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the missing ceiling tile.


4. Observation on December 5, 2022, at 9:50 am, revealed, in basement fire pump room, the sprinkler gauges were dated 2013, exceeding the 5-year service interval.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the gauges were beyond the 5-year service interval.






Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Corridor - Doors

Name - BUILDING 06 (TAYLOR A BUILDING) Component - 21
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:

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of corridor doors, affecting one of four levels in the facility.

Findings include:

1. Observations on December 5, 2022, between 9:50 am and 9:54 am, revealed missing door hardware in the following locations:

a. 9:50 am, 1st floor, Storage;
b. 9:54 am, 1st floor, Janitor's closet.

Exit interview with the Director of Facilities on December 5, 2022, at 12:30 pm, confirmed the missing door hardware.




Plan of Correction:

An approved Plan of Correction is not on file.


Initial Comments:
Name - BUILDING 08 (NORTH CAMPUS B SIDE) Component - 40

Facility ID #037201
Component 40
North Campus Building B Side

Based on a Relicensure Survey conducted on December 5 - 8, 2022, it was determined that Crozer Chester Medical Center -North Campus Building B Side, was not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy.

This is a five-story, Type I (222), fire-resistive construction, which is fully sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Multiple Occupancies

Name - BUILDING 08 (NORTH CAMPUS B SIDE) Component - 40
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:
* They are not intended to serve four or more inpatients.
* They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
* The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of common wall separations, affecting two of five floors.

Findings include:

1. Observations on December 8, 2022, revealed fire rated common wall deficiencies in the following locations:

a. 9:50 am, ground floor B-building, above the sally-port, unsealed penetration around data wires.
b. 10:00 am, 2nd floor B-building, above stair tower doors, penetration around data wire bundle.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the common wall deficiencies.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Stairways and Smokeproof Enclosures

Name - BUILDING 08 (NORTH CAMPUS B SIDE) Component - 40
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 smoke resistance of stairways, affecting one of four levels in the component.

Findings include:

1. Observation on December 8, 2022, at 10:15 am, revealed, in the 1st floor, open penetrations by MC cable and data wires above the exit door to the Center Stairwell.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the open penetrations.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Exit Signage

Name - BUILDING 08 (NORTH CAMPUS B SIDE) Component - 40
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:

Based on document review and interview, it was determined the facility failed to ensure that exit signs were maintained, affecting one of five floors.

Findings include:

1. Document review on December 8, 2022, at 10:25 am, revealed, above 3rd floor exit doors at main stair tower, the exit sign was missing its faceplate.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the missing signage.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Spinkler System - Installation

Name - BUILDING 08 (NORTH CAMPUS B SIDE) Component - 40
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:

Based on observation and interview, it was determined the facility failed to maintain complete automatic sprinkler protection, affecting one of five floors.

Findings Include:

1. Observation made on December 8, 2022, at 10:20 am, revealed, 3rd floor across from room 413, the suspended ceiling has been permanently removed and the sprinklers have not been reoriented up.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed incomplete sprinkler coverage.





Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - BUILDING 08 (NORTH CAMPUS B SIDE) Component - 40
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:

Based on observation and interview, it was determined the facility failed to maintain sprinkler systems, affecting one of four levels in the component.

Findings include:

1. Observations made on December 8, 2022, between 9:45 am and 9:50 am, revealed storage within 18" of a sprinkler in the following locations:

a. 9:45 am, lower level, EVS Linen Room;
b. 9:50 am, lower level, Mechanical Room.

Interview at the exit conference with the Facility Director and the Facility Manager on December 8, 2022, at 11:00 am, confirmed the storage within 18" of a sprinkler.




Plan of Correction:

An approved Plan of Correction is not on file.


NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie

Name - BUILDING 08 (NORTH CAMPUS B SIDE) Component - 40
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 fire rating of the smoke barrier walls, affecting one of five floors.

Findings include:

1. Observation on December 8, 2022, at 9:55 am, revealed, 2nd floor above the smoke doors by waiting room, an unsealed penetration around data wires.

Interview at the exit conference with the Facility Director and the Facility Manager on
December 8, 2022, at 11:00 am, confirmed the penetration.





Plan of Correction:

An approved Plan of Correction is not on file.