Initial Comments:
Name - KEYSTONE HOSPICE Component - 01
Facility ID# 159399
Component 01
Based on a Recertification/Relicensure Survey completed on February 14, 2024, it was determined Keystone Hospice 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 three story, Type V (000), unprotected wood frame building, with a basement, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - KEYSTONE HOSPICE Component - 01
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, document review, and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire facility.
Findings include:
Observation and document review on February 14, 2024, between 8:15 a.m. and 9:45 a.m., revealed the facility has been classified as a three-story unprotected wood frame building, with a basement, that is fully sprinklered. The maximum story height exceeds two levels in an unprotected wood frame construction.
Exit Interview with the Facility Administrator and Director of Maintenance on February 14, 2024, at 9:45 a.m., confirmed the facility construction type and story height.
Plan of Correction:The Keystone Hospice facility requests that the PA Department of Health update our FSES and that we are brought up to and accepted under the Life Safety Cole 101 NFPA 2012 to meet this Observation #0161. This will be monitored by the Facility Administrator.
NFPA 101 STANDARD
Stairways and Smokeproof Enclosures
Name - KEYSTONE HOSPICE Component - 01
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2
Observations:
Based on observation, document review, and interview, it was determined the facility failed to maintain the fire resistance rating of stairway enclosures, affecting four of four levels.
Findings include:
Observation and document review on February 14, 2024, between 8:15 a.m. and 9:45 a.m., revealed components for Stair Tower #1 lacked a 1 1/2-hour fire rating on each floor level.
Exit Interview with the Facility Administrator and Director of Maintenance on February 14, 2024, at 9:45 a.m., confirmed the fire resistance rating of the stairway enclosure was not maintained.
Plan of Correction:The Keystone Hospice facility requests that the PA Department of Health update our FSES and that we are brought up to and accepted under the Life Safety Code 101 NFPA 2012 to meet this observation #0225. This will be monitored by the Facility Administrator.
NFPA 101 STANDARD
Aisle, Corridor, or Ramp Width
Name - KEYSTONE HOSPICE Component - 01
Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
Observations:
Based on observation, document review, and interview, it was determined the facility failed to maintain corridors with a minimum four-foot clearance, affecting four of four levels within the facility.
Findings include:
Observation and document review on February 14, 2024 between 8:15 a.m. and 9:45 a.m., revealed the corridor widths were less than 48 inches on each floor level.
Exit Interview with the Facility Administrator and Director of Maintenance on February 14, 2024, at 9:45 a.m., confirmed minimum corridor widths were not maintained.
Plan of Correction:The Keystone Hospice facility requests that the PA Department of Health update our FSES and that we are brought up to and accepted under the Life Safety Code 101 NFPA 2012 to meet this Observation #0232. This will be monitored by the Facility Administrator.
NFPA 101 STANDARD
Clear Width of Exit and Exit Access Doors
Name - KEYSTONE HOSPICE Component - 01
Clear Width of Exit and Exit Access Doors
2012 EXISTING
Exit access doors and exit doors are of the swinging type and are at least 32 inches in clear width. Exceptions are provided for existing 34-inch doors and for existing 28-inch doors where the fire plan does not require evacuation by bed, gurney, or wheelchair.
19.2.3.6, 19.2.3.7
Observations:
Based on observation, document review, and interview, it was determined the facility failed to maintain minimum widths of exit doors, affecting two of four levels within the facility.
Findings include:
Observation and document review on February 14, 2024, between 8:15 a.m. and 9:45 a.m., revealed the clear width of exit discharge doors was less than 32 inches, at the following locations:
a. Exit door G10E clear width was 31 inches, outside the Heating, Ventilating, and Air Conditioning closet on the basement level.
b. Exit door 102EX clear width was 31.5 inches, outside the cloud room, First-Floor level.
Exit Interview with the Facility Administrator and Director of Maintenance on February 14, 2024, at 9:45 a.m., confirmed minimum clear width of exit doors was not maintained.
Plan of Correction:The Keystone Hospice Facility requests that the PA Department of Health update our FSES and that we are brought up to and accepted under the Life Safety Code 101 NFPA 2012 to meet this Observation #0233. This will be monitored by the Facility Administrator.
NFPA 101 STANDARD
Number of Exits - Story and Compartment
Name - KEYSTONE HOSPICE Component - 01
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Based on observation, document review, and interview, it was determined the facility failed to maintain two approved means of egress, affecting two of four levels within the facility.
Findings include:
Observation and document review on February 14, 2024, between 8:15 a.m. and 9:45 a.m., revealed there was one exit stair tower leading directly to the outside, Second and Third Levels. A minimum of two remote exits are required per floor.
Exit Interview with the Facility Administrator and Director of Maintenance on February 14, 2024, at 9:45 a.m., confirmed the lack of two remote exits.
Plan of Correction:The Keystone Hospice Facility requests that the PA Department of Health update our FSES and that we are brought up to and accepted under the Life Safety Code 101 NFPA 2012 to meet this Observation #0241. This will be monitored by the Facility Administrator.
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