QA Investigation Results

Pennsylvania Department of Health
BUCKTAIL MEDICAL CENTER, THE
Building Inspection Results

BUCKTAIL MEDICAL CENTER, THE
Building Inspection Results For:


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Initial Comments:
Name - MAIN BUILDING Component - 01

Facility ID# 549601
Component 01
Main Building

Based on a Relicensure Survey completed on June 14, 2021, it was determined that Bucktail Medical Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a one story, Type II (111), protected, noncombustible building, with penthouse, that is fully sprinklered.




Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - MAIN BUILDING Component - 01
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.


Observations:

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in eight locations, affecting one of one floor.

Findings include:

1. Observation on June 14, 2021, between 9:00 a.m. and 10:12 a.m., revealed the following:

a. 9:00 a.m., a ceiling diffuser within the Phone Room lacked a fire damper.
b. 9:02 a.m., a hole within the suspended ceiling assembly of the Phone Room.
c. 9:04 a.m., a penetration of the ceiling assembly within the Oxygen Room.
d. 9:08 a.m., a penetration of the rated ceiling assembly within Room 102.
e. 9:10 a.m., residential exhaust within the X-Ray Restroom lacked a fire damper.
f. 9:32 a.m., combustible paper backing, affixed to insulating materials, within the Acute Restroom.
g. 9:44 a.m., large openings within the monolithic portion of the rated ceiling assembly, due to recessed lighting fixture removal, within Resident Room 210.
h. 10:12 a.m., the piped-in oxygen system overhang is constructed of combustible materials.

Exit interview with the Facility Administrator and the Facilities Manager on June 14, 2021, between 10:45 a.m. and 11:00 a.m., confirmed the building construction deficiencies.





Plan of Correction:

a. A damper was installed on the diffuser in the phone room and the diffuser was marked to indicate it was equipped with a Damper. The damper will be cleaned and inspected in November 2021, when all dampers in the facility are due for cleaning and inspection, and then every 4 years.

Maintenance Director will add diffuser in phone room as a quality indicator for the Quality Improvement (QI) program until the damper is cleaned and inspected in November 2021. Results of the indicator will be presented at the monthly QI meetings.

b. The hole within the suspended ceiling assembly of the phone room was sealed with fireproof caulking.

c. The ceiling tile with the penetration of the ceiling assembly in the oxygen was replaced with a new rated ceiling tile.

d. The ceiling tile with a penetration of the rated ceiling assembly in room 102 was replaced with a new rated ceiling tile.

e. The residential exhaust within the X-Ray restroom has been removed and replaced with a rated ceiling tile. The Maintenance Director did a visual inspection of the rest of the facility to identify any other residential exhausts; none were identified.

f. The combustible paper backing affixed to insulating materials within the acute restroom has been removed from the insulating material.

g. The large openings within the monolithic portion of the ceiling assembly have been corrected by placing rated ceiling tiles in the openings of the rated ceiling to close the openings.

Maintenance Director has added ceiling penetrations as a quality indicator of the facility Quality Improvement (QI) program. Maintenance Director or designee will per form a weekly visual inspection throughout the facility weekly to identify any ceiling penetrations. Results of the visual inspections will be presented at the monthly QI meetings. The indicator will remain active until no new ceiling penetrations are identified for three consecutive months.

h. The portion of the piped in oxygen overhang constructed of combustible lumber will be treated with Flamex PF-2 Fire Retardant Spray For Exterior Wood in accordance with the manufacturer's instructions. Flamex PF-2 Fire Retardant Spray For Exterior Wood will be applied every five years, in accordance with the manufacture's recommendations.

Maintenance Director has added application of Flamex PF-2 Fire Retardant Spray For Exterior Wood to the portion of the piped in oxygen overhang constructed of combustible lumber every five years has been added as a quality indicator for the facility QI program. The indicator will remain active in the program until the portion of the piped in oxygen overhang constructed of combustible lumber is re-treated with Flamex PF-2 Fire Retardant Spray For Exterior Wood on or before June 2026.



NFPA 101 STANDARD
Means of Egress - General

Name - MAIN BUILDING Component - 01
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 in one location, affecting one of one floor.

Findings include:

1. Observation on June 14, 2021, at 9:45 a.m., revealed a lift and a wheelchair blocked the exit discharge door within the 200 Hallway.

Exit interview with the Facility Administrator and the Facilities Manager on June 14, 2021, between 10:45 a.m. and 11:00 a.m., confirmed the means of egress deficiency.





Plan of Correction:

The lift and wheelchair that blocked the exit discharge door within the 200 Hallway were immediately relocated to clear the discharge door at the end of the 200 Hallway.

Nursing staff will receive in-service training for maintaining fire exits clear of obstructions and for proper storage of items in hallways.

This training will be added to the annual education provided to every employee annually.



NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - MAIN BUILDING 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 sprinkler water storage tank, affecting the entire facility.

Findings include:

1. Documentation review and interview on June 14, 2021, at 10:40 a.m., revealed the facility could not produce documentation of an interior tank inspection, due since 2018.

Exit interview with the Facility Administrator and the Facilities Manager on June 14, 2021, between 10:45 a.m. and 11:00 a.m., confirmed the automatic sprinkler system maintenance and testing deficiency.








Plan of Correction:

Several calls have been made to both Johnson Controls Inc. and Clemmer Fire Protection and Northwoods Fire Protection. The sprinkler system water storage tank interior inspection will be scheduled as soon as we receive a response from one of the above contractors.

Maintenance Director will review sprinkler system water storage tank interior inspection annually in May of each year.


Sprinkler system water tank interior inspection has been added as a quality indicator for the Quality Improvement (QI) program.


The Maintenance Director will report on the status of the sprinkler system water tank at each May QI meeting.


The sprinkler system water tank will next be due for inspection in June 2026. The sprinkler system water tank interior inspection will remain a quality indicator until the interior tank inspection is completed in June 2024.



NFPA 101 STANDARD
Corridor - Doors

Name - MAIN BUILDING Component - 01
Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. 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 one corridor opening, affecting one of one floor.

Findings include:

1. Observation on June 14, 2021, at 9:50 a.m., revealed the Dish Room door did not close freely due to door drag.

Exit interview with the Facility Administrator and the Facilities Manager on June 14, 2021, between 10:45 a.m. and 11:00 a.m., confirmed the corridor opening deficiency.




Plan of Correction:

The Dish Room door has been readjusted so it opens and closes freely without door drag. Doors throughout the facility were checked for door drag; none were found.
Door drag of the Dish Room door has been added as a quality indicator for the facility Quality Improvement (QI) program. The door will be checked weekly for door drag. The results of the weekly checks will be reported at the monthly QI meetings. The indicator will remain active until no door drag on the Dish Room door is reported for three consecutive months.



NFPA 101 STANDARD
Smoking Regulations

Name - MAIN BUILDING Component - 01
Smoking Regulations
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
18.7.4, 19.7.4

Observations:

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one location, affecting one of one floor.

Findings include:

1. Observation on June 14, 2021, at 9:33 a.m., revealed extinguished cigarettes were located within the trash receptacle, at the Emergency Room entrance area, at the exterior of the building.

Exit interview with the Facility Administrator and the Facilities Manager on June 14, 2021, between 10:45 a.m. and 11:00 a.m., confirmed the smoking regulations deficiency.





Plan of Correction:

The trash receptacle at the Emergency Room entrance area at the exterior of the building was immediately removed.
New "No Smoking" signs have been ordered and will be installed at the Emergency Room entrance area.

All staff will be required to review the Smoking Policy in the resident handbook.

Review of the smoking policy will be added to the annual education provided to every employee annually.