QA Investigation Results

Pennsylvania Department of Health
CHANDLER HALL HEALTH SERVICES, INC.
Building Inspection Results

CHANDLER HALL HEALTH SERVICES, INC.
Building Inspection Results For:


There are  29 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - MAIN BUILDING 01 Component - 01

Facility ID# 150299
Component 01
Main Healthcare Building Hospice

Based on a Relicensure Survey completed on October 19, 2022, it was determined that Chandler Hall Health Services, Inc. was not in compliance with the following requirements of the Life Safety Code for an existing Hospice health care occupancy.

This is a one-story, Type V (000), unprotected wood frame construction, with an unused attic and partial basement, which is fully sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - MAIN BUILDING 01 Component - 01
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 document review and interview, it was determined the facility failed to maintain the fire alarm system, affecting the entire facility.

Findings include:

1. Document review on October 19, 2022, at 9:30 a.m., revealed the fire alarm inspection report, dated September 27, 2022, listed the following deficiencies which remained uncorrected at time of survey:

a. two pull stations would not open.
b. two batteries, Main FACP, failed at 10%.

Exit Interview with the Administrator and Maintenance Directors on October 19, 2022, at 12:15 p.m., confirmed the Fire Alarm deficiencies.





Plan of Correction:

a. Fire system service company has been engaged to repair the two pull stations.
b. Fire System service company has been engaged to replace the two batteries for Main FACP, failed at 10%
Date of Correction: December 1, 2022



NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - MAIN BUILDING 01 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 document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Document review on October 19, 2022, at 9:30 a.m., revealed the September 12, 2022, sprinkler inspection report listed the following deficiencies:

a. Systems 1-4 are due for three year full flow and five year internal inspections.
b. Systems 1-4 are being filled with air from the nitrogen system air compressor, multiple leaks on the 1, 2, 3, and 4 dry systems.
c. Pool Hallway has a pinhole in the piping and the dry pendant in the bathroom is removed pending replacement.
d. Out of date water gauges and air gauges on all systems.

Evidence of corrective action was not available at time of survey.

Exit Interview with the Administrator and Maintenance Directors on October 19, 2022, at 12:15 p.m., confirmed the sprinkler system deficiencies.

2. Document review on October 19, 2022, at 9:30 am, revealed the facility could not produce documentation showing Second and Fourth Quarter sprinkler inspections had been conducted during the prior 12 months.

Exit Interview with the Administrator and Maintenance Directors on October 19, 2022, at 12:15 p.m., confirmed the missing documentation.

3. Observation on October 19, 2022, at 11:15 a.m., revealed a missing sprinkler escutcheon, resident room 120.

Exit Interview with the Administrator and Maintenance Directors on October 19, 2022, at 12:15 p.m., confirmed the missing escutcheon.





Plan of Correction:

1.
a. Fire System service company will provide quotes and complete work for Systems 1-4.
b. Fire System service company will provide quotes and complete work on Systems 1-4 nitrogen system air compressor and multiple leaks.
c. Fire System service company will complete work for the pool hallway. The replacement part for the bathroom has been ordered and will be installed in December for our quarterly inspection.
d. Fire System service company will replace the out-of-date gauges including the water gauges. They will be replaced in our December quarterly inspection.
Date of Correction: December 1, 2022

2. Documents are on file of Second and fourth quarter sprinkler inspection.
Date of Completion: 10/31/2022

3. Missing escutcheon for Hospice Room 120 was fixed. Work order # 23773
Date of Completion: October 19, 2022



NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste

Name - MAIN BUILDING 01 Component - 01
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:

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

Findings include:

1. Document review on October 19, 2022, at 9:30 a.m., revealed the facility could not produce documentation showing a three year, four hour exercise of the generator had been performed on the Onan generator.

Exit Interview with the Administrator and Maintenance Director on October 19, 2022, at 12:15 p.m., confirmed the missing documentation for the required exercise.

2. Document review on October 19, 2022, at 9:35 a.m., revealed the October 28, 2021, generator fuel quality report determined the existing fuel cannot be deemed fit for use per NFPA 110, life safety and ASTM specifications.

Exit Interview with the Administrator and Maintenance Directors on October 19, 2022, at 12:15 p.m., confirmed the generator fuel deficiency.





Plan of Correction:

1. Documents are on file for the Onan Generator.
Date of Completion: October 28, 2022

2. Fuel sample was taken. Waiting for the results. A request for time limited waiver has been sent to the div of Life Safety to allow time to complete this work.
Date of completion: December 1, 2022



NFPA 101 STANDARD
Electrical Equipment - Power Cords and Extens

Name - MAIN BUILDING 01 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 one floor.

Findings include:

1. Observation on October 19, 2022, at 11:20 a.m., revealed, Resident Room 120, a fridge plugged into surge protector.

Exit Interview with the Administrator and Maintenance Directors on October 19, 2022, at 12:15 p.m., confirmed the unauthorized electrical device.





Plan of Correction:

Hospice Room 120 fridge was plugged into surge protector. Fridge is now plugged into an outlet. Work order # 23773.

Date of Completion October 19, 2022