Initial Comments:
Name - BUILDING 04 Component - 10
Facility ID# 152199
Component 10
Building 04
Based on a Recertification/Relicensure Survey completed on May 24, 2021, at Lehigh Valley Hospice, Inc. was not in compliance with the following requirements of the Life Safety Code for an existing Hospice health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 418.110 (d).
This is a seven story, Type II (222), fire resistive building, with a basement and rooftop mechanical spaces, that is fully sprinklered..
Plan of Correction:
NFPA 101 STANDARD
Alcohol Based Hand Rub Dispenser (ABHR)
Name - BUILDING 04 Component - 10
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Observations:
Based on observation and interview, it was determined the facility failed to monitor the installation of alcohol-based hand rub dispensers on one of one floors.
Findings include:
1. Observation on May 24, 2021, at 12:30 p.m., revealed a ABHR dispenser installed installed within an inch of an ignition source.
Interview at the time of the exit conference with the Director of Engineering, on May 24, 2021, at 12:45 p.m., confirmed the ABHR was directly over an electrical light switch.
Plan of Correction:The hand sanitizer was relocated May 24th, 2021, the day of inspection.
Staff were instructed that the installation requirements of hand sanitizer dispensers over electrical switches, outlets or flammable materials such as linen, hampers, or trash cans is prohibited.
Reviewed with staff locations of dispensers on the unit to confirm locations currently comply with standards and will continue to review locations as part of their monthly Environment of Care rounds documented in the Facilities Management office.
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