Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 13, 2021, at St. Luke's Hospice, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - MAIN Component - 02
Facility ID# 153599
Component 02
Main Building
Based on a Recertification/Relicensure Survey completed on May 13, 2021, it was determined that St. Luke's Hospice was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).
This is a one story, Type V (111), protected, wood frame building, with unused attic space, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Exit Signage
Name - MAIN 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, it was determined the facility failed to install and maintain exit signage in two locations, affecting one of one floor.
Findings include:
1. Observation on May 13, 2021, between 11:40 a.m. and 11:42 a.m., revealed both sets of smoke barrier separation walls lacked exit signage.
Exit interview with the facilities manager on May 13, 2021, between 12:10 p.m. and 12:15 p.m., confirmed the exit signage deficiencies.
Plan of Correction:In compliance with Exit Signage 2012, illuminated exit signs will be installed on the lobby side above both sets of smoke barrier doors by June 20, 2021.
St. Luke's Hospice will ensure that the inpatient facility meets the edition of NFPA Life Safety Code and all applicable appendices of compliance which are currently enforced by the Federal Government and any subsequent edition with exception to any new construction, which will meet the current standard.
To ensure compliance and quality assurance, Environmental Services checklist will include visual inspection that the exit signs are unobstructed weekly for a period of 3 months for 100% compliance. Exit signs will be added to the yearly emergency lighting logs maintained by St. Luke's engineering.
Responsible parties are the Director of Plant Operations, St. Luke's Bethlehem campus, Vice President of Hospice, Facilities and Purchasing Manager, VNA of St. Luke's and Hospice Patient Care Manager, Inpatient Unit.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN Component - 02
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 automatic sprinkler system in one location, affecting one of one floor.
Findings include:
1. Observation on May 13, 2021, at 11:30 a.m., revealed an escutcheon plate was lacking on the automatic sprinkler head assembly within Patient Room 4.
Exit interview with the facilities manager on May 13, 2021, between 12:10 p.m. and 12:15 p.m., confirmed the sprinkler system deficiency.
Plan of Correction:To maintain compliance with NFPA 25, missing escutcheon was replaced and completed on May 14, 2021.
St. Luke's Hospice will ensure that the inpatient facility meets the edition of NFPA Life Safety Code and all applicable appendices of compliance which are currently enforced by the Federal Government and any subsequent edition with exception to any new construction, which will meet the current standard.
To ensure compliance and quality assurance, all areas will be monitored weekly by the Environmental Service Aide for intact escutcheon in all areas of the Hospice House. Upon detection of any missing assemblies, work order will be placed with St. Luke's Bethlehem engineering department to have replaced immediately.
Responsible parties are the Director of Plant Operations, St. Luke's Bethlehem campus, Vice President of Hospice, Facilities and Purchasing Manager, VNA of St. Luke's and Hospice Patient Care Manager, Inpatient Unit.
NFPA 101 STANDARD
Corridor - Doors
Name - MAIN Component - 02
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. 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 corridor openings in one location, affecting one of one floor.
Findings include:
1. Observation on May 13, 2021, at 11:40 a.m., revealed the distance between the kitchen doors exceeded one-eighth-inch.
Exit interview with the facilities manager on May 13, 2021, between 12:10 p.m. and 12:15 p.m., confirmed the corridor opening deficiency.
Plan of Correction:To maintain compliance with NPFA 101 Standard regarding corridor doors, corridor doors to the kitchen were adjusted to one-eighth inch between doors. This work was completed on May 17, 2021.
St. Luke's Hospice will ensure that the inpatient facility meets the edition of NFPA Life Safety Code and all applicable appendices of compliance which are currently enforced by the Federal Government and any subsequent edition with exception to any new construction, which will meet the current standard.
To ensure compliance and quality assurance, the kitchen doors will be measured weekly to ensure distance does not exceed one-eighth inch for a period of three months with 100% compliance, there after doors will be measured on the yearly fire door inspection performed by St. Luke's Engineering Dept – Bethlehem.
Responsible parties are the Director of Plant Operations, St. Luke's Bethlehem campus, Vice President of Hospice, Facilities and Purchasing Manager, VNA of St. Luke's and Hospice Patient Care Manager, Inpatient Unit.
NFPA 101 STANDARD
Electrical Systems - Other
Name - MAIN Component - 02
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to maintain the generator set in one location, affecting one of one floor.
Findings include:
1. Observation on May 13, 2021, at 11:50 a.m., revealed the generator set lacked an externally-locate shut-off/emergency stop button.
Exit interview with the facilities manager on May 13, 2021, between 12:10 p.m. and 12:15 p.m., confirmed the generator set deficiency.
Plan of Correction:To maintain compliance with NFPA 110, 2010 edition- Emergency and Standby Power Systems regarding a remote manual stop station located shut-off/emergency stop button, a remote manual stop station will be installed and labeled by June 21, 2021.
St. Luke's Hospice will ensure that the inpatient facility meets the edition of NFPA Life Safety Code and all applicable appendices of compliance which are currently enforced by the Federal Government and any subsequent edition with exception to any new construction, which will meet the current standard.
To ensure compliance and quality assurance, the remote manual stop will be checked by the outside vendor servicing the generator yearly and documentation will be maintained showing same.
Responsible parties are the Director of Plant Operations, St. Luke's Bethlehem campus, Vice President of Hospice, Facilities and Purchasing Manager, VNA of St. Luke's and Hospice Patient Care Manager, Inpatient Unit.
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