Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on January 4 - 5, 2024, it was determined that Norristown State Hospital was not in compliance with the requirements of 42 CFR 482.15.
Plan of Correction:
482.15(a)(3) STANDARD
EP Program Patient Population
Name - Component - --
§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3).
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**
*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following:
(3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
*NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]
Observations:
Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness program addressing the patient population, affecting the entire facility.
Findings include:
Documentation reviewed on January 4, 2024, revealed the Facility's Emergency Preparedness plan did not address patient/client population, persons at risk, and the type of services the facility has the ability to provide in an emergency.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the EP plan did not specify the population served within the facility, in the event of an emergency.
Plan of Correction:NSH will update and maintain the Emergency Operations Plan annually, including Mutual Aid Agreements, and addressing the types of services NSH can provide in an emergency.
Completed 3/18/2024
The NSH Safety Manager will perform an annual review of our Emergency Operations Plans.
482.15(d)(2) STANDARD
EP Testing Requirements
Name - Component - --
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) testing program to conduct exercises to test the emergency plan, affecting the entire facility.
Findings include:
Documentation reviewed on January 4, 2024, revealed the facility failed to conduct exercises to test the emergency plan twice per year. Documentation was provided for an individual facility-based exercise conducted in March 2023. A second full-scale community-based, individual, facility-based functional exercise, mock disaster drill, tabletop exercise or workshop led by a facilitator that included a group discussion was not available at the time of survey.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the facility failed to conduct required exercises for the Emergency Preparedness plan.
Plan of Correction:NSH will conduct at least two emergency exercises annually to test elements of the EOP. One of the exercises will include Community Partners (Red Cross, etc.).
Completed 3/18/2024
The NSH Safety Manager will ensure preparedness during the annual review of the Emergency Operations Plan.
Initial Comments:
Name - COMPONENT 12 (BUILDING 1) Component - 12
Facility ID# 40050100
Component 12
Building 1
Based on an unannounced Medicare Recertification Survey completed on January 4 - 5, 2024, it was determined that Norristown State Hospital - Building 1 was not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 482.41(b).
This is a two-story, Type II (222), fire resistive construction, with a basement and mechanical penthouse, which is non-sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Stairways and Smokeproof Enclosures
Name - COMPONENT 12 (BUILDING 1) Component - 12
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 and interview, it was determined the facility failed to maintain the fire resistance rating of stair enclosures, affecting 1 of four levels (Building 1).
Findings include:
Observation on January 5, 2024, revealed partially sealed conduit penetrations in the corner of the stair wall, First Floor, A wing, short hall, above the stair enclosure door.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unsealed penetrations in the above named location.
Plan of Correction:NSH Maintenance Department will fill conduit penetrations using the proper Hilti Firestop product and systems.
Completed 3/18/2024
NSH maintenance personnel will ensure penetrations are sealed after construction activities are completed.
NFPA 101 STANDARD
Illumination of Means of Egress
Name - COMPONENT 12 (BUILDING 1) Component - 12
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Observations:
Based on observation and interview, it was determined the facility failed to maintain required illumination of the means of egress, affecting 1 of four levels (Building 1).
Findings Include:
Observation on January 5, 2024, revealed Stair 5 lacked two forms of illumination at the exit discharge, in the event one bulb becomes inoperable, Ground Floor.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the exit discharge required additional illumination.
Plan of Correction:Illumination of Means of Egress were addressed and repaired onsite on 1/5/2024, providing two forms of illumination at the exit discharge in the event one form of illumination becomes inoperable.
Completed 1/5/2024
NSH Fire Safety Marshal will ensure compliance during the monthly fire safety inspection.
NFPA 101 STANDARD
Vertical Openings - Enclosure
Name - COMPONENT 12 (BUILDING 1) Component - 12
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, it was determined the facility failed to maintain the fire resistance rating of vertical openings, affecting 1 four levels (Building 1).
Findings include:
Observation on January 5, 2024, revealed inside Mechanical Shaft 1088, next to the Laundry Room, there was a large opening in the ceiling and an unsealed duct penetration in the rear of the space. The duct penetration lacked access to verify installation of a fire damper, First Floor, E Wing.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unprotected vertical openings.
Plan of Correction:We are consulting with our Division of Facilities and Property Management to determine if the opening in the mechanical shaft was sealed or open. Also, we will inspect the duct to determine if a fire damper is present and required.
Completed 3/18/2024
NSH maintenance staff will complete any necessary work based upon the outcome of the DFPM survey.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - COMPONENT 12 (BUILDING 1) Component - 12
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 sprinkler system components in operable condition, affecting 3 of four levels (Building 1).
Findings include:
Documentation reviewed on January 4, 2024, revealed the internal sprinkler inspection & testing report dated February 1, 2022 for the linen chutes and Toggery room indicated they were unable to complete internal testing and were unable to shut the system down. Gauge valves are corroded and there was a clog in the system. The 4" OS&Y valve should be replaced. Verification of repair was not available at the time of inspection.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the deficienct sprinkler components.
Plan of Correction:Repair was completed by Johnson Controls and the Five Year internal inspection was completed on the same day. Documentation was unavailable during inspection - repairs had not yet been completed at that time.
Completed 2/12/2024
NSH Fire Safety Marshal will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NFPA 101 STANDARD
Corridor - Doors
Name - COMPONENT 12 (BUILDING 1) Component - 12
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 positive self-latching on corridor doors, affecting 2 of four floor levels (Building 1).
Findings include:
Observation on January 5, 2024, revealed there was a dogged-down feature on the latching device on the top half of the Med room corridor dutch door, located on each resident sleeping floor level, E Wing.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the impediment to door latching.
Plan of Correction:NSH Maintenance Staff (Locksmith) will remove feature which allows door to be dogged down.
Completed 3/18/2024
Door opening/closing/locking inspections will be incorporated into NSH Fire Safety Marshal's monthly inspections.
NFPA 101 STANDARD
HVAC
Name - COMPONENT 12 (BUILDING 1) Component - 12
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
Observations:
Based on document review and interview, it was determined the facility failed to maintain HVAC (Heating, Ventilating, and Air Conditioning) equipment in operable condition, affecting 1 out of 205 dampers (Building 1).
Findings Include:
Documentation reviewed on January 4, 2024, revealed the damper inspection & testing report indicated damper 293 was not powered. Verification of repair was not available at the time of survey.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the damper was not functioning.
Plan of Correction:NSH Maintenance technicians (Electrical Shop) will ensure that the damper is provided with electrical power and is operational.
Completed 3/18/2024
NSH Fire Safety Marshal will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NFPA 101 STANDARD
Electrical Systems - Maintenance and Testing
Name - COMPONENT 12 (BUILDING 1) Component - 12
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 1).
Findings include:
1. Documentation reviewed on January 4, 2024, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:
a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the facility could not provide documentation the receptacles were tested.
Plan of Correction:We are consulting with the PA DOH Patient Care Surveyors for their guidance for what rooms are considered patient care/treatment rooms at our facility. We will institute a program to inspect the electric receptacles in those areas. Maintenance has begun weekly visual inspections of these systems for long-term compliance.
Completed 3/18/2024
NSH will initiate an inspection program (once guidance is received from PA DOH) performed by our maintenance electricians and managed by the Facility Operations Manager to ensure compliance.
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - COMPONENT 12 (BUILDING 1) Component - 12
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, readily identifiable, and separate from normal power circuits. 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 observation, document review and interview, it was determined the facility failed to maintain required inspections and components of the Essential Electrical System, affecting the entire facility (Building 1).
Findings include:
1. Documentation reviewed performed on January 4, 2024, revealed the facility could not produce documentation of the following required testing and inspections for the emergency generator:
a. Weekly visual inspections of the generator;
b. Monthly battery conductance testing;
c. Annual 90 minute Load Bank testing:
d. No evidence of wet-stacking;
e. three (3) year, four (4) hour load test;
f. Annual fuel quality test.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing documentation.
2. Observation made on January 5, 2024, revealed the emergency generator transfer switch location lacked emergency back-up lighting.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing emergency lighting.
Plan of Correction:A Purchase Order (PO) was originated on 2/8/2024, to have a vendor complete the necessary inspections in order to maintain components. New weekly and monthly checksheets have been in use since January 2024. A back up light source will be added to the transfer switch location.
(1a) Maintenance has begun a weekly visual inspection program to verify the status of the generator.
(2) Maintenance will install emergency lighting in the area to improve visibility by 04/01/2024
Completed 2/8/2024 and 4/1/2024
NSH maintenance department will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NSH Fire Safety Marshal will test emergency lighting as part of their updated inspection procedures.
Initial Comments:
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
Facility ID# 40050100
Component 23
Building 51
Based on an unannounced Medicare Recertification Survey completed on January 4 - 5, 2024, it was determined that Norristown State Hospital - Building 51 Forensic Unit, was not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 482.41(b).
This is a three-story, Type II (222), fire resistive construction, (ground, first, second floor), and a rooftop elevator machine room penthouse, which is non-sprinklered.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General 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.
Observations:
28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.
35 P.S. 448.808. Issuance of license.
(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.
Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility.
Findings include:
Observation and document review made on January 5, 2024, revealed the facility failed to secure plan approval by the Department of Health (Department) prior to initiating alterations to remove fire doors and seal the opening separating the tunnel at the A Wing, ground floor (Building 51).
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024 at 12:30 p.m., confirmed the facility failed to obtain Department-approved plans prior to initiating alterations and renovations.
28 Pa Code 51.3. Notification (d)
Plan of Correction:DHS DFPM has been contacted to verify location of removed fire door and frame and new infill of fire rated wall opening construction for compliance with the LSC. DFPM will submit drawings to PA DOH Division of Safety Inspection for plan review and approval of the subject alteration. Any additional building improvements, once approved, will be conducted by facility maintenance personnel.
Completion: 60-90 days depending on availability of DOH plan review schedules.
Any construction or renovation that may involve building fire separations will not occur until a thorough review of building drawings and actual site investigation is performed by facility maintenance personnel and DFPM engineers.
NFPA 101 STANDARD
Means of Egress - General
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Based on observation and interview, it was determined the facility failed to maintain means of egress free from obstructions, affecting 1 of four levels (Building 51).
Findings Include:
Observation made on January 5, 2024, revealed the facility was unable to locate keys to exit doors in a timely manner. There were several attempts to locate the appropriate key to Stair B door 1032, 1st floor.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the impediment to egress.
Plan of Correction:The NSH Nursing Department will add additional training for the Sallyport staff to have the necessary knowledge to use the secure key to unlock the exterior door in the event of a building evacuation.
Completion 4/1/2024
During the monthly fire safety inspection performed by our Fire Safety Marshal, the staff working in the Sallyport will be questioned on the location of the key required to exit the building.
NFPA 101 STANDARD
Vertical Openings - Enclosure
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
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, it was determined the facility failed to maintain the fire resistance rating of vertical openings, affecting 1 of four levels (Building 51).
Findings include:
Observation on January 5, 2024, revealed the fire extinguisher cabinet was recessed into the shaft wall near electrical panel 1C DSGS-1985, First Floor, A Wing.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the integrity of the enclosure was compromised.
Plan of Correction:We are consulting with our Division of Facilities and Property Management to determine if the space behind the fire extinguisher cabinet is a shaft or void space.
Completed 3/18/2024
NSH maintenance staff will make any necessary work based upon the outcome of the DFPM survey.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
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 sprinkler system components in operable condition, affecting 1 of three systems (Building 51).
Findings include:
Documentation reviewed on January 4, 2024, revealed the internal sprinkler inspection & testing report dated February 1, 2022 for the linen chutes indicated only 2 of 3 laundry chute systems were clear and one pipe on the system was corroded. Verification of repairs was not available at the time of inspection.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the deficienct sprinkler components.
Plan of Correction:Purchase Order was originated on 1/11/2024 and the repairs were completed by Johnson Controls on 3/19/2024.
NSH Fire Safety Marshal will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NFPA 101 STANDARD
Corridor - Doors
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
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 ensure corridor doors resisted the passage of smoke and positively latched into their frames, affecting 1 of four levels (Building 51).
Findings include:
1. Observation made on January 5, 2024, revealed the Lawyers waiting room corridor door was propped open with a chair. The door had a self-closing device installed, 1st floor.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the corridor door obstruction.
Plan of Correction:Maintenance (Lock Shop) removed the self-closing device.
Completed 3/18/2024
NSH Fire Safety Marshal will ensure compliance during the monthly fire safety inspection.
NFPA 101 STANDARD
Utilities - Gas and Electric
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2
Observations:
Based on observation and interview, it was determined the facility failed to ensure electrical wiring was protected, affecting 1 of four levels (Building 51).
Findings include:
Observation on January 5, 2024, revealed there was an open junction box with exposed inner wiring above the ceiling, near the smoke barrier partition, outside the Nurses' Station, First Floor, A Wing;
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unprotected electrical wiring.
Plan of Correction:The junction box was secured during the LSC inspection.
Completed 1/5/2024
NSH Fire Safety Marshal will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NFPA 101 STANDARD
HVAC
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
Observations:
Based on document review and interview, it was determined the facility failed to maintain HVAC (Heating, Ventilating, and Air Conditioning) equipment in operable condition, affecting 2 out of 205 dampers (Building 51).
Findings Include:
Documentation reviewed on January 4, 2024, revealed the damper inspection & testing report indicated two fire dampers were inaccessible. Verification access had been provided was not available at the time of survey:
a. 183;
b. 268.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the dampers were not inspected.
Plan of Correction:Brand Services (damper inspection and repair vendor) will verify the existence of the two inaccessible dampers.
Completed 3/18/2024
NSH Fire Safety Marshal will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NFPA 101 STANDARD
Electrical Systems - Maintenance and Testing
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 51).
Findings include:
1. Documentation reviewed on January 4, 2024, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:
a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the facility could not provide documentation the receptacles were tested.
Plan of Correction:We are consulting with the PA DOH Patient Care Surveyors for their guidance for what rooms are considered patient care/treatment rooms at our facility. We will institute a program to inspect the electric receptacles in those areas. Maintenance has begun weekly visual inspections of these systems for long-term compliance.
Completed 3/18/2024
NSH will initiate an inspection program (once guidance is received from PA DOH) performed by our maintenance electricians and managed by the Facility Operations Manager to ensure compliance.
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - COMPONENT 23 (FORENSIC UNIT BUILDING 51) Component - 23
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, readily identifiable, and separate from normal power circuits. 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 observation, document review and interview, it was determined the facility failed to maintain required inspections and components of the Essential Electrical System, affecting the entire facility (Building 51).
Findings include:
1. Documentation reviewed on January 4, 2024, revealed the facility could not produce documentation of the following required testing and inspections:
a. Weekly visual inspection of the generator;
b. 30 minute load testing on a consistent basis
(e.g. no load test 9/8/23);
c. Monthly battery conductance testing;
d. Annual 90 minute Load Bank testing:
e. No evidence of wet-stacking;
f. three (3) year, four (4) hour load test;
g. Annual fuel quality test.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing documentation.
2. Observation made on January 5, 2024, revealed the emergency generator transfer switch location lacked emergency back-up lighting.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing emergency lighting.
Plan of Correction:A Purchase Order (PO) was originated on 2/8/2024, to have a vendor complete the necessary inspections in order to maintain components. New weekly and monthly checksheets have been in use since January 2024. A back up light source will be added to the transfer switch location.
(1a) Maintenance has begun a weekly visual inspection program to verify the status of the generator.
(2) Maintenance will install emergency lighting in the area to improve visibility by 04/01/2024.
Completed 2/8/2024 and 4/1/2024
NSH maintenance department will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NSH Fire Safety Marshal will test emergency lighting as part of their updated inspection procedures.
Initial Comments:
Name - COOMPONENT 67 (BUILDING 10) Component - 67
Facility ID# 40050100
Component 67
Building 10
Based on an unannounced Medicare Recertification Survey completed on January 4 - 5, 2024, it was determined that Norristown State Hospital - Building 10, was not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 482.41(b).
This is a two-story, Type II(222), fire resistive construction, with a basement and mechanical penthouse, which is non-sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Exit Signage
Name - COOMPONENT 67 (BUILDING 10) Component - 67
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 ensure exit directional signs were installed, affecting 1 of four levels (Building 10).
Findings include:
Observation on January 5, 2024, revealed the Center Hall lacked exit signage, E Wing, Second Floor.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the lack of exit signage.
Plan of Correction:NSH will install directional exit signage in the Center Hall, Building 10E2.
Completed 3/18/2024
The NSH Fire Safety Marshal will ensure that all signage is intact during the monthly safety inspection.
NFPA 101 STANDARD
Vertical Openings - Enclosure
Name - COOMPONENT 67 (BUILDING 10) Component - 67
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, it was determined the facility failed to maintain the fire resistance rating of vertical openings between floors, affecting 2 of four levels (Building 10).
Findings include:
1. Observation on January 5, 2024, revealed on the First Floor, in the D-1 Nurses' Station Med Room, inside Pipe Chase Closet 1018, there were four (4) unsealed pipes penetrating the floor slab.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unsealed vertical penetrations.
2. Observation on January 5, 2024, revealed there was an opening in the wall above the duct penetrating the shaft wall inside the Cafeteria, First Floor, E Wing. In addition, the installation of perimeter-mounting angles could not be determined.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the vertical openings in the above named locations.
Plan of Correction:(1) Maintenance staff will fill penetrations using proper Hilti Firestop products and systems.
(2) Maintenance will photograph problematic areas and consult with DFPM to have them rectified. Maintenance will install perimeter angles around the duct in question.
Completed 3/18/2024
NSH Maintenance staff will make any necessary work based upon the outcome of the DFPM survey.
NFPA 101 STANDARD
Portable Fire Extinguishers
Name - COOMPONENT 67 (BUILDING 10) Component - 67
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Based on observation and interview, it was determined the facility failed to ensure fire extinguishers were installed properly, affecting 1 of four levels (Building 10).
Findings include:
Observation on January 5, 2024, revealed in the Second Floor, D-2 short hall, near Room 2011, the recessed fire extinguisher and locator light above the extinguisher had been removed.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the fire extinguisher removal.
Plan of Correction:The Division of Facilities and Property Management (DFPM) were consulted and approved a plan for NSH to move portable fire extinguishers from direct patient areas to nursing stations. DFPM made notifications to commonwealth survey agencies in 2023.
Completed 3/18/2024
NSH Fire Safety Marshal will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NFPA 101 STANDARD
Corridor - Doors
Name - COOMPONENT 67 (BUILDING 10) Component - 67
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 positive self-latching on corridor doors, affecting 2 of four levels (Building 10).
Findings include:
Observation on January 5, 2024, revealed there was a dogged-down feature on the latching device on the top half of the Med room corridor dutch door, located on each resident sleeping floor level, E Wing.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the impediment to door latching.
Plan of Correction:Maintenance (Lock Shop) removed the self-closing device.
Completed 3/18/2024
NSH Fire Safety Marshal will ensure compliance during the monthly fire safety inspection.
NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie
Name - COOMPONENT 67 (BUILDING 10) Component - 67
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
Observations:
Based on observation and interview, it was determined the facility failed to ensure smoke barrier walls were free of unsealed penetrations, affecting 1 of five smoke zones (Building 10).
Findings include:
Observation on January 5, 2024, revealed on the First Floor above smoke barrier door 1012, near the Visitation Room 1011, there was a wire cut out penetration through the smoke barrier wall.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the smoke barrier wall penetration.
Plan of Correction:NSH will repair penetrations with Hilti Fire Stop caulk.
Maintenance staff will properly fill the penetration with proper Hilti Firestop products and systems.
Completed 3/18/2024
Upon completion of any project/construction activity, the Maintenance Department Supervisor will do a final inspection to confirm all penetrations are filled using the proper Hilti Firestop Products and Systems.
NFPA 101 STANDARD
HVAC
Name - COOMPONENT 67 (BUILDING 10) Component - 67
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain protection of Heating, Ventilation, and Air Conditioning (HVAC) systems, affecting 1 of four levels (Building 10).
Findings include:
Observation on January 5, 2024, revealed there was a fire damper approximately one foot from the shaft wall. This was one of three ducts in the passage corridor outside the visitor's lobby, Second Floor, E Wing. In addition, the installation of perimeter-mounting angles could not be determined.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the location of the fire damper.
Plan of Correction:Brand Services will verify placement of the affected damper. NSH will install perimeter mounting angles/supports on these ducts.
Completed 3/18/2024
NSH Fire Safety Marshal will ensure that documentation of all repairs and inspections is maintained and readily available for review.
NFPA 101 STANDARD
Electrical Systems - Maintenance and Testing
Name - COOMPONENT 67 (BUILDING 10) Component - 67
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 10).
Findings include:
1. Documentation reviewed on January 4, 2024, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:
a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the facility could not provide documentation receptacles were tested.
Plan of Correction:We are consulting with the PA DOH Patient Care Surveyors for their guidance for what rooms are considered patient care/treatment rooms at our facility. We will institute a program to inspect the electric receptacles in those areas. Maintenance has begun weekly visual inspections of these systems for long-term compliance.
Completed 3/18/2024
NSH will initiate an inspection program (once guidance is received from PA DOH) performed by our maintenance electricians and managed by the Facility Operations Manager to ensure compliance.
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - COOMPONENT 67 (BUILDING 10) Component - 67
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, readily identifiable, and separate from normal power circuits. 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 observation, document review and interview, it was determined the facility failed to maintain required inspections and components of the Essential Electrical System, affecting the entire facility (Building 10).
Findings include:
1. Documentation reviewed on January 4, 2024, revealed the facility could not produce documentation of the following required testing and inspections:
a. Weekly visual inspection of the generator;
b. 30 minute load testing on a consistent basis
(e.g. no load test in 2023 on 1/18, 2/7, 3/14, 5/15, June, 7/24, 9/8, and 11/16);
c. Monthly battery conductance testing;
d. Annual 90 minute Load Bank testing:
e. No evidence of wet-stacking;
f. 3 year, 4-hour load test;
g. Annual fuel quality test.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing documentation.
2. Observation made on January 5, 2024, revealed the emergency generator transfer switch location lacked emergency back-up lighting.
Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing emergency lighting.
Plan of Correction:A Purchase Order (PO) was originated on 2/8/2024, to have a vendor complete the necessary inspections in order to maintain components. New weekly and monthly checksheets have been in use since January 2024. A back up light source will be added to the transfer switch location.
(1a) Maintenance has begun a weekly visual inspection program to verify the status of the generator.
(2) Maintenance will install emergency lighting in the area to improve visibility by 04/01/2024.
Completed 2/8/2024 and 4/1/2024
"NSH Maintenance Department will ensure that documentation of all repairs and inspections is maintained and is readily available for review.
NSH Fire Safety Marshal will test emergency lighting as part of their updated inspection procedures.
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