QA Investigation Results

Pennsylvania Department of Health
AHN HEMPFIELD NEIGHBORHOOD HOSPITAL
Building Inspection Results

AHN HEMPFIELD NEIGHBORHOOD HOSPITAL
Building Inspection Results For:


There are  11 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 - FIRST FLOOR HOSPITAL Component - 01
Facility ID# 50520101
Component 01
AHN Hempfield Neighborhood Hospital

Based on a Relicensure Survey completed on November 22, 2022, it was determined that AHN Hempfield Neighborhood Hospital, was not in compliance with the following requirements of the Life Safety Code for new health care occupancy.

This is a three-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.



Plan of Correction:




NFPA 101 STANDARD
Vertical Openings - Enclosure

Name - FIRST FLOOR HOSPITAL Component - 01
Vertical Openings - Enclosure
2012 NEW
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 2 hours connecting four or more stories. (1 hour for single story building and buildings up to three stories in height.) An atrium may be used in accordance with 8.6.7.
18.3.1 through 18.3.1.5

Observations:
Based on observation and interview, it was determined the facility failed to maintain the vertical opening enclosures in two instance, affecting the entire facility.

Findings include:

1. Observation on November 22, 2022, revealed the following vertical opening enclosure deficiencies;

a) 11:28 a.m., there were multiple large conduits in the floor and ceiling of the MDF room, that were being sealed with a non-rated foam.
b) 11:38 a.m., there was an unsealed pipe penetration in the concrete deck above, located in the 3508 electrical emergency room.

Interview with the Facility Administrator and the Maintenance Supervisor on November 22, 2022, at 12:30 p.m., confirmed the vertical opening enclosure deficiencies.





Plan of Correction:

In response to SO311 1a, Non Rated foam has been removed and the penetrations have been sealed with a UL rated Fire barrier sealant to prevent smoke and heat from escaping the room reducing the sensors effectiveness via work order EMER3802618 in the CMMS system. S0311 1a has been completed and has no further actions pending as of 12/7/2022.
In response to SO311 1b, the penetrations have been sealed with a UL rated Fire barrier sealant to prevent smoke and heat from escaping the room reducing the sensors effectiveness via work order EMER3802619 in the CMMS system. S0311 1b has been completed and has no further actions pending as of 12/7/2022


NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - FIRST FLOOR HOSPITAL 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 documentation review and interview, it was determined the facility failed to perform required fire alarm system testing and maintenance, affecting the entire facility.

Findings Include:

1. Review of documentation on November 22, 2022, at 9:20 a.m., revealed the facility failed to perform the following required smoke detector sensitivity testing.

a) one year after initial installation;
b) biennial sensitivity testing there after.

Interview with the Facility Administrator and Maintenance Supervisor on November 22, 2022, at 12:30 p.m., confirmed the facility failed to perform the above listed required smoke detector sensitivity testing.






Plan of Correction:

In response to S0345 1,1a and 1b), the Landlord's Management group has provided documentation showing that the detector sensitivity test was perfumed on 4/26/2022. They are setting a contracted schedule with the vendor to complete the test biennially. A CMMS work order schedule has been developed to track this and notify when the testing is due at a biennial schedule. S0345 1a and 1b has been completed per documentation of 4/26/2022 and no further actions are pending.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - FIRST FLOOR HOSPITAL 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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instances, affecting one of two smoke compartments.

Findings include:

1.Observation on November 22, 2022, at 11:33 a.m., revealed the facility failed to maintain a smoke/heat resistive ceiling for the proper activation /operation, of the automatic sprinkler system. There were multiple unsealed penetration in the ceiling of the bio-med room.

Interview with the Facility Administrator and the Maintenance Supervisor on November 22, 2022, at 12:30 p.m., confirmed the automatic sprinkler system deficiency.





Plan of Correction:

In response to S0353 1), the penetrations have been sealed with a UL rated Fire barrier sealant to prevent smoke and heat from escaping the room reducing the sensors effectiveness via work order EMER3802620 in the CMMS system. S0353 1 has been completed as of 12/7/2022 and no further actions are pending.


NFPA 101 STANDARD
Fire Drills

Name - FIRST FLOOR HOSPITAL Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Observations:
Based on documentation review and interview, it was determined the facility failed to perform one of eight required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on November 22, 2022, at 9:10 a.m., revealed the facility lacked documentation for a third quarter fire drill, for the second shift.

Interview with the Facility Administrator and Maintenance Supervisor on November 22, 2022, at 12:30 p.m., confirmed the facility lacked documentation for the above listed fire drill.





Plan of Correction:

In response to S0712 all fire drills will be conducted at various times throughout the quarter to capture each shift and will be tracked via a Day Shift work order and a Night Shift work order in the CMMS system. S0712 1 has been completed as of 12/7/2022 and will be maintained monthly.


NFPA 101 STANDARD
Electrical Systems - Essential Electric Sys

Name - FIRST FLOOR HOSPITAL 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 to 40 day intervals, and exercised once every 36 months for four 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 documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing, affecting the entire facility.

Findings include:

1. Review of documentation on November 22, 2022, at 9:40 a.m., revealed the facility failed to perform the following emergency generator maintenance and testing:

a) weekly voltage;
b) monthly conductance;
c) annual preventative maintenance;
d) annual load bank;
e) annual fuel quality;

Interview with the Facility Administrator and Maintenance Supervisor, on November 22, 2022, at 12:30 p.m., confirmed the facility failed to perform the above listed emergency generator maintenance and testing.






Plan of Correction:

In response to SO918 we have updated our weekly generator inspection to include a form that adds the voltage readings and conductance testing. This has been added to the CMMS program and is being dispatched weekly for the technicians to fill out and add back to the cmms work orders prior to closing them out. S00918 1a has been completed as of 12/5/2022 and will deploy in the CMMS system hence forth.
In response to SO918 we have updated our weekly generator inspection to include a form that adds the voltage readings and conductance testing. This has been added to the CMMS program and is dispatched weekly for the technicians to fill out and add back to the cmms work orders prior to closing them out. S00918 1b has been completed as of 12/5/2022 and will deploy in the CMMS system hence forth.
In response to S0918 1d, A CMMS Work order has been generated and dispatched to the generator vendor for the completion of the annual load bank and scheduled for completion by 12/31/2022.
In response to S0918 1e, A CMMS Work order has been generated and dispatched to the generator vendor for the completion of the annual fuel quality sampling and scheduled for completion by 12/31/2022


NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag

Name - FIRST FLOOR HOSPITAL Component - 01
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Based on observation and interview, it was determined the facility failed to properly store medical gas cylinders in one instance, affecting the entire facility.

Findings include:

1. Observation on November 22, 2022, at 11:48 a.m., revealed the following:

a. Oxygen and medical gas cylinders stored outside were not protected from weather;
b. Oxygen and medical gas cylinders were stored in the same enclosure as motor driven equipment (generator).

Interview with the Facility administrator and the Maintenance Supervisor on November 22, 2022, at 12:30 p.m., confirmed the medical gas cylinder storage deficiencies.






Plan of Correction:

In response to S09323 1a and 1b, all exterior medical gas cylinders that are being stored outside and In the generator enclosure area are being removed from the sites. The storage of extra tanks will no longer be the practice as we have enhanced our MedGas/MedAir system and no longer have a need for the additional cylinders. S09323 1a and 1b has been completed as of 12/7/2022


Initial Comments:
Name - BRENTWOOD CAMPUS Component - 10

Facility ID# 50520101
Component 10
Brentwood Neighborhood Hospital

Based on a Relicensure Survey completed on November 23, 2022, it was determined that AHN Brentwood Neighborhood Hospital was not in compliance with the following requirements of the Life Safety Code for new health care occupancy.

This is a two-story, Type II (222), fire resistive building, without a basement, that is fully sprinklered.






Plan of Correction:




NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - BRENTWOOD CAMPUS Component - 10
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 instance, affecting one of two smoke compartments.

Findings include:

1. Observation on November 24, 2022, at 10:55 a.m., revealed there was a gap greater than 1/8" around conduit in the ceiling tile of the housekeeping closet of the inpatient area.

Interview with Administrative and Maintenance Staff on November 24, 2022, at 11:00 a.m., confirmed the automatic sprinkler system deficiency.




Plan of Correction:

In response to S0353 1), the penetrations have been sealed with a UL rated Fire barrier sealant to prevent smoke and heat from escaping the room reducing the sensors effectiveness via work order EMER3702255 in the CMMS system. This work has been completed as of 12/5/2022


NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag

Name - BRENTWOOD CAMPUS Component - 10
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to properly store medical gas cylinders in one instance, affecting the entire facility.

Findings include:

1. Observation on November 24, 2022, at 9:55 a.m., revealed the following:

a. Oxygen and medical gas cylinders stored outside were not protected from weather;
b. Oxygen and medical gas cylinders were stored in the same enclosure as motor driven equipment (generator).

Interview with Administrative and Maintenance Staff on November 24, 2022, at 11:00 a.m., confirmed the medical gas cylinder storage deficiencies.






Plan of Correction:

In response to S09323 1a and 1b, all exterior medical gas cylinders that are being stored outside and In the generator enclosure area are being removed from the sites. The storage of extra tanks will no longer be the practice as we have enhanced our MedGas/Medair system and no longer have a need for the additional cylinders. S09323 1a and 1b has been completed as of 12/7/2022


Initial Comments:
Name - MCCANDLESS CAMPUS Component - 20

Facility ID# 50520101
Component 20
Main Building-McCandless Neighborhood Hospital

Based on a Relicensure Survey completed on November 16, 2022, it was determined that AHN Hempfield Neighborhood Hospital - McCandless was not in compliance with the following requirements of the Life Safety Code for new health care occupancy.

This is a four-story, Type II (222), fire resistive building, without a basement, that is fully sprinklered.






Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - MCCANDLESS CAMPUS Component - 20
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 observation and interview, it was determined the facility failed to properly maintain the fire alarm system in two instances, affecting one of four smoke compartments.

Findings include:

1. Observation on November 16, 2022, revealed missing ceiling tiles in the following locations, that would allow heat and smoke to bypass the automatic fire alarm system detectors:

a) 11:58 a.m., in the first floor storage room near the breakdown room;
b) 12:38 p.m., in the housekeeping room near the CT Procedure room on the first floor.

Interview with the Facility Regional CEO and Maintenance Supervisor on November 16, 2022, at 1:30 p.m., confirmed the missing ceiling tiles.






Plan of Correction:

In response to SO345 1a, the ceiling tiles have been replaced to prevent smoke and heat from escaping the room reducing the sensors effectiveness via work order EMER3802619 in the CMMS system. This work has been completed as of 12/5/2022
In response to SO345 1b, the ceiling tiles have been replaced to prevent smoke and heat from escaping the room reducing the sensors effectiveness via work order EMER3602152 in the CMMS system. This work has been completed as of 12/5/2022


NFPA 101 STANDARD
Subdivision of Building Space - Smoke Barrier

Name - MCCANDLESS CAMPUS Component - 20
Subdivision of Building Spaces - Smoke Barrier Construction
2012 NEW
Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems.
18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3
Describe any mechanical smoke control system in REMARKS.

Observations:

Based on observation and interview, it was determined the facility failed to properly maintain smoke barrier walls in two instances, affecting four of four smoke compartments.

Findings include:

1. Observation on November 16, 2022, revealed the following smoke barrier deficiencies:

a) 12:36 p.m., there was non-rated foam in a conduit above the smoke doors, near Exam Room 8, on the first floor;
b) 12:45 p.m., there was an unsealed wire penetration in the smoke barrier wall on the second floor, across the corridor from Stair 2.

Interview with the Facility Regional CEO and Maintenance Supervisor on November 16, 2022, at 1:30 p.m., confirmed the smoke barrier deficiencies.




Plan of Correction:

In response to SO372 1a, Non Rated foam has been removed and the penetrations have been sealed with a UL rated Fire barrier sealant to prevent smoke and heat from escaping the room reducing the sensors effectiveness via work order EMER3602154 in the CMMS system. This work has been completed as of 12/5/2022
In response to SO372 1b, the penetrations have been sealed with a UL rated Fire barrier sealant to prevent smoke and heat from escaping the room reducing the sensors effectiveness via work order EMER3602153 in the CMMS system. This work has been completed as of 12/5/2022


NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag

Name - MCCANDLESS CAMPUS Component - 20
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to properly store medical gas cylinders in one instance, affecting the entire facility.

Findings include:

1. Observation on November 16, 2022, at 10:50 a.m., revealed the following:

a. Oxygen and medical gas cylinders stored outside were not protected from weather;
b. Oxygen and medical gas cylinders were stored in the same enclosure as motor driven equipment (generator).

Interview with the Facility Maintenance Supervisor on November 16, 2022, at 1:30 p.m., confirmed the medical gas cylinder storage deficiencies.









Plan of Correction:

In response to S0923 1a and 1b, all exterior medical gas cylinders that are being stored outside and In the generator enclosure area are being removed from the sites. The storage of extra tanks will no longer be the practice as we have enhanced our MedGas/MedAir system and no longer have a need for the additional cylinders. S0923 1a and 1b has been completed as of 12/7/2022


Initial Comments:
Name - AHN HARMAR Component - 30


Facility ID# 50520101
Component 30
Harmar Neighborhood Hospital

Based on a Relicensure Survey completed on November 21, 2022, it was determined that AHN Hempfield Neighborhood Hospital - Harmar was not in compliance with the following requirements of the Life Safety Code for new health care occupancy.

This is a two-story, Type II (222), fire resistive building, without a basement, that is fully sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - AHN HARMAR Component - 30
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 documentation review and interview, it was determined the facility failed to maintain the fire alarm system, in one instance, affecting the entire facility


Findings Include:

1.Review of documentation on November 21, 2022, at 9:00 a.m., revealed the facility lacked documentation that the biennial smoke detector sensitivity was performed.

Interview with the Facility Administator and Maintenance Director on November 21, 2022, at 9:00 a.m., confirmed the facility lacked documentation for the biennial smoke detector sensitivity testing.






Plan of Correction:

In response to S0345 1, the Landlord's Management group is working with their Fire Safety vendor to complete a smoke detector sensitivity test and provide the results for review. They will then set a contracted schedule with the vendor to complete the test biennially. A CMMS work order schedule has been developed to track this and notify when the testing is due at a biennial schedule. The schedule has been set and deployed and is due for completion by 12/31/2022.


NFPA 101 STANDARD
Corridor - Doors

Name - AHN HARMAR Component - 30
Corridor - Doors
2012 NEW
Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between bottom of door and floor covering is not exceeding 1 inch. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted.
Doors shall be provided with self-latching and positive latching hardware. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials.
18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatic closing devices, etc.

Observations:
Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of four smoke compartments.

Findings include:

1. Observation on November 21, 2022, at 9:38 a.m., revealed the door to the second floor staff lounge failed to latch in place when tested.


Interview with the Facility Administrator and Maintenance Director on November 21, 2022, at 11:00 a.m., confirmed the corridor door deficiency.




Plan of Correction:

In response to S0363 1, The latch has been repaired to ensure it makes full contact each time it is engaged and verified through multiple closures as of 12/6/2022 via work order EMER4001483.


NFPA 101 STANDARD
Electrical Systems - Essential Electric Sys

Name - AHN HARMAR Component - 30
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 to 40 day intervals, and exercised once every 36 months for four 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 documentation review and interview, it was determined the facility failed to perform emergency generator maintenance testing for 12 of the last 12 months.

Findings include:

1. Review of documentation on November 21, 2022, at 8:30 a.m., revealed the facility lacked documentation verifying that the emergency generator preventative maintenance was performed in the last 12 months.

Interview with the Facility Administrator and Maintenance Director, on November 21, 2022, at 8:30 a.m., confirmed the required yearly generator testing documentation was not available at the time of the survey.







Plan of Correction:

In response to S0918 1, A CMMS Work order has been generated and dispatched to the generator vendor for the completion of the annual preventative maintenance on the generator and is scheduled to be completed by 12/31/2022.


NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag

Name - AHN HARMAR Component - 30
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:


Based on observation and interview, it was determined the facility failed to properly store medical gas cylinders in one instance, affecting the entire facility.

Findings include:

1. Observation on November 21, 2022, at 9:50 a.m., revealed the following:

a. Oxygen and medical gas cylinders stored outside were not protected from weather;
b. Oxygen and medical gas cylinders were stored in the same enclosure as motor driven equipment (generator).

Interview with the Facility Maintenance Supervisor on November 21, 2022, at 11:00 a.m., confirmed the medical gas cylinder storage deficiencies.







Plan of Correction:

In response to S0923 1a and 1b, all exterior medical gas cylinders that are being stored outside and In the generator enclosure area are being removed from the sites. The storage of extra tanks will no longer be the practice as we have enhanced our MedGas/MedAir system and no longer have a need for the additional cylinders. S09323 1a and 1b has been completed as of 12/7/2022