Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on February 22-28, 2024, at Select Specialty Hospital - Erie, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.
Plan of Correction:
Initial Comments:
Name - SELECT SPECIALTY HOSPITAL ERIE Component - 02
Facility ID # 08230101
Component 02
Main Building
Based on an abbreviated survey that was part of a complaint investigation completed on February 22-28, 2024, it was determined that Select Specialty Hospital-Erie was not in compliance with the licensure requirements for a health care facility.
This is a four-story, Type II (222), fire resistive building, with a penthouse and basement, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - SELECT SPECIALTY HOSPITAL ERIE Component - 02
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, the facility failed to inspect and maintain the building construction type for a Type II (222)-rated building, affecting one of over two building roof sections.
Findings include:
Observation and interview on February 22, 2024, at 10:17 a.m., revealed the boiler room roofline had a section of rubber roofing material (measuring approximately 80 feet squared) used as a temporary fix. The material was laying over the existing roofline, and there were weights placed to secure it from movement. Additionally, the temporary material was tight against the boiler exhaust pipe without a rated thimble in place.
Through interview on a previous date, the boiler exhaust reached a temperature high enough that caused the roof material to fail/melt. The building management group was responsible for the roof repairs and had completed the temporary fix.
Observation on February 28, 2024, revealed the weights were removed and the rubber roofing material was secured in place. There was also a thimble in place around the section of boiler exhaust, but it was unknown at the time of the survey if the repair or material was approved/rated for this application. Further discussions indicated that the facility failed to obtain required approval from the Department of Health State Plan Review and receive a granted occupancy from the Life Safety Division for this project.
Interview with the director of plant operations and maintenance technician on February 28, 2024, at 10:17 a.m., confirmed the deficiencies.
Plan of Correction:To ensure compliance with building inspection and maintenance in accordance with NFPA 101, a certified roofing contractor, hired by the building management group, completed roof repairs on February 23, 2024.
The Director of Plant Operations, or designee, will complete Plan Review submission by March 31, 2024. Plan Review submission will include material used and standards followed.
Compliance with the above plan will be monitored by the Director of Plant Operations, or designee, by inspecting the roof during monthly Environment of Care Rounds. This will continue until acceptable compliance has been achieved and sustained. At that time, monitoring will be part of the hospital's ongoing Quality Assurance Performance Improvement (QAPI) Plan via monthly Environment of Care Rounds. Findings will be reported monthly to the QAPI Team and quarterly to the Organization Improvement Committee (OIC), Medical Executive Committee (MEC) and Governing Board (GB). The Director of Plant Operations will continue to collaborate with building management group to ensure all repairs are completed in a timely manner as necessary.
The Director of Plant Operations is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.
The hospital will be in full compliance with the above date by March 31, 2024.
NFPA 101 STANDARD
Doors with Self-Closing Devices
Name - SELECT SPECIALTY HOSPITAL ERIE Component - 02
Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
Observations:
Based on observation and interview, the facility failed to maintain doors with self-closing devices on one of six building levels.
Findings include:
Observation on February 22, 2024, between 9:30 a.m. and 9:34 a.m., revealed the following self-closure deficiencies:
A. (9:30 a.m.) Penthouse east door was damaged and would not close and latch in the frame. The facility provided an invoice that indicated that the door was in the process of being replaced;
B. (9:34 a.m.) Penthouse west door was damaged and would not close and latch in the frame. The facility provided an invoice that indicated that the door was in the process of being replaced;
Interview with the director of plant operations and maintenance technician on February 28, 2024, at 9:34 a.m., confirmed the door deficiencies.
Plan of Correction:To ensure compliance with doors with self-closing devices in accordance with NFPA 101, the Director of Plant Operations, or designee, will provide education to all staff members within the maintenance department and contracted security staff on the importance of keeping doors closed at all times to prevent wind damage. Education will be completed no later than March 31, 2024.
Replacement doors were ordered on February 19, 2024. Estimated time of delivery and installation is April 5, 2024. Interim Life Safety Measures (ILSM) were initiated on February 19, 2024 and will continue until installation of doors is complete.
Compliance with the above plan will be monitored by Director of Plant Operations, or designee, by monitoring the closing and latching of Penthouse doors during monthly Environment of Care Rounds. This will continue until acceptable compliance has been achieved and sustained. At that time, monitoring will be part of the hospital's ongoing QAPI Plan via monthly Environment of Care Rounds. Findings will be reported monthly to the QAPI Team and quarterly to the Organization Improvement Committee (OIC), Medical Executive Committee (MEC) and Governing Board (GB).
The Director of Plant Operations is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.
The hospital will be in full compliance with the above date by April 5, 2024.
NFPA 101 STANDARD
Exit Signage
Name - SELECT SPECIALTY HOSPITAL ERIE Component - 02
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 observation and interview, the facility failed to maintain two of more than twenty-five emergency exit signs.
Observation on February 22, 2024, between 9:38 a.m. and 11:30 a.m., revealed the following exit sign deficiencies:
A. (9:38 a.m.) Fourth floor elevator B lobby had a directional exit sign that lacked illumination;
B. (11:30 a.m.) First-floor corridor from the elevator lobby to the back of the building (north side) lacked an illuminated directional exit sign.
Interview with the maintenance technician on February 22, 2024, at 11:30 a.m., confirmed the exit sign deficiencies.
Plan of Correction:To ensure compliance with Exit Signage in accordance with NFPA 101, the Director of Plant Operations, or designee, has secured an electrical contractor to install illuminated exit signs in locations identified. Anticipated completion date for installation of illuminated exit signs is March 22, 2024. Interim Life Safety Measures (ILSM) initiated and will remain in place until installation of illuminated exit signs is complete.
Compliance with the above plan will be monitored by Director of Plant Operations, or designee, by inspecting exit signs during monthly preventative maintenance. This will continue until acceptable compliance has been achieved and sustained. At that time, monitoring will be part of the hospital's ongoing QAPI Plan via annual evaluation of all exit signage to ensure all signs in place meet code requirements. Findings will be reported monthly to the QAPI Team and quarterly to the Organization Improvement Committee (OIC), Medical Executive Committee (MEC) and Governing Board (GB).
The Director of Plant Operations is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.
The hospital will be in full compliance with the above date by March 22, 2024.
NFPA 101 STANDARD
Vertical Openings - Enclosure
Name - SELECT SPECIALTY HOSPITAL ERIE Component - 02
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Based on observation and interview, the facility failed to maintain vertical openings in four of eight vertical shafts.
Findings include:
Observation on February 22, 2024, between 9:46 a.m. and 10:30 a.m., revealed the following vertical shaft doors failed to close and latch in the frame:
A. (9:46 a.m.) Fourth-floor shaft door, located next to the east nurses' station;
B. (9:57 a.m.) Fourth-floor west corridor had two vertical shaft doors that were adjusted to properly close and latch at the time of the survey;
C. (10:30 a.m.) Third floor shaft door, located between rooms 304 and 305.
Interview with the maintenance technician on February 22, 2024, at 10:30 a.m., confirmed the vertical door deficiencies.
Plan of Correction:To ensure vertical openings are maintained in accordance with NFPA 101, new springs were purchased and installed on all shaft doors.
Compliance with the above plan will be monitored by the Director of Plant Operations, or designee, by inspecting shaft doors for overuse or malfunction during monthly Environment of Care Rounds. This will continue until acceptable compliance has been achieved and sustained. At that time, monitoring will be part of the hospital's ongoing QAPI Plan by including shaft doors in the Pre-construction Infection Control Risk Assessment for future projects. Findings will be reported monthly to the QAPI Team and quarterly to the Organization Improvement Committee (OIC), Medical Executive Committee (MEC) and Governing Board (GB).
The Director of Plant Operations is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.
The hospital will be in full compliance with the above date by March 11, 2024.
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