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 Revisit to 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 substantial 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 building, that is fully sprinklered.
Plan of Correction:
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.
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During an offsite Revisit conducted on January 9, 2025, at 7:35 a.m., the following was revealed:
Item 1. Not Completed. On the third floor, Stair #9 delayed egress door failed to open after 15 seconds.
Exit Interview with the Facilities Director on January 9, 2025, at 10:37 a.m., confirmed the delayed egress door failed to open within the maximum time frame permitted.
Plan of Correction:The Director of Facilities will ensure the new door coordinator hardware is installed by 3/15/25.
The Director of Facilities is ultimately responsible for this plan of correction.
Initial Comments:
Name - BUILDING 05 (TAYLOR HOSPITAL MAIN BUILDING) Component - 20
Facility ID #037201
Component 20
Taylor Hospital Main Building
Based on a Revisit to a Relicensure Survey conducted on December 5 - 8, 2022, it was determined that Crozer Chester Medical Center Taylor Hospital was in substantial compliance with the requirements of the Life Safety Code for an existing Hospital health care occupancy.
This is a five story, Type II (222), fire resistive building, that is fully sprinklered.
Plan of Correction:
Initial Comments:
Name - BUILDING 06 (TAYLOR A BUILDING) Component - 21
Facility ID # 037201
Component 21
Taylor Hospital A Building
Based on a Revisit to a Relicensure Survey conducted on December 5 - 8, 2022, it was determined that Crozer Chester Medical Center Taylor Hospital A Building was in substantial compliance with the requirements of the Life Safety Code for an existing Hospital health care occupancy.
This is a three-story, Type II(222), fire-resistive building, with a basement, that is fully sprinklered.
Plan of Correction:
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