QA Investigation Results

Pennsylvania Department of Health
CLARKS SUMMIT STATE HOSPITAL
Building Inspection Results

CLARKS SUMMIT STATE HOSPITAL
Building Inspection Results For:


There are  34 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed May 22-23, 2024, at Clarks Summit State Hospital, it was determined there were no deficiencies identified with the requirements of 42 CFR 482.15.




Plan of Correction:




Initial Comments:
Name - MAIN BUILDING 06 Component - 01

Facility ID # 55090100
Component 01
Building 06
Hilltop West

Based on an unannounced Medicare Recertification Survey completed May 22-23, 2024, it was determined that Clarks Summit State Hospital was not in compliance with the requirements of the Life Safety Code for an existing psychiatric 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 one story, Type II (000), unprotected, noncombustible building, with a basement, that is nonsprinklered.








Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - MAIN BUILDING 06 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 provide the required building construction type, affecting the entire component

Findings include:

1. Observation on May 23, 2024, at 10:00 a.m., revealed the building is a Type II (000) construction type, and lacks the complete automatic sprinkler system protection that is required for this type of construction.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the component requires a complete automatic sprinkler system protection.








Plan of Correction:

The Department of General Services has approved capital project 502-34 to install sprinklers in Building 06, Hilltop West. Construction began May 22, 2023, and be completed June 13, 2025. As of 06/04/24 this project is 65% completed.


NFPA 101 STANDARD
Corridor - Doors

Name - MAIN BUILDING 06 Component - 01
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 three corridor openings, affecting one of one floor.

Findings include:

1. Observation on May 23, 2024, between 10:00 a.m., and 10:32 a.m., revealed the following:

a. 10:00 a.m., the Main Dining Room door 1080 lacked positive latching capabilities (roller latches).
b. 10:06 a.m., the Main Dining Room door B-27 lacked positive latching capabilities (hardware removed).
c. 10:32 a.m., the Resident Room door 15-18 door was not smoke-tight.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the corridor opening defciencies.





Plan of Correction:

The Main Dining Room Doors are used frequently. normal wear and tear caused the door latching mechanism to fail and the doors to become smoke tight.

The Facility Operations Supervisor created a work order on 05/23/24, to correct the positive latching mechanism on doors (a.)1080 Work Order # 24050242 and (b.) B-27 Work Order # 24050226. The latching mechanism was adjusted on both doors 1080 and B-27 on 05/24/24.

The Facility Operations Supervisor created a work order on 05/23/24, to correct the door that was not smoke tight on (c.) bedroom door 15-18 Work Order # 24050225. The door was adjusted to be smoke tight on 05/30/24.

The Facility Operations Manager 2 notified the Fire Safety Marshal and The Institutional Safety Manager on 5/30/24, that the door latching mechanisms on doors (a.) 1080 and (b.) B-27 were adjusted.

The Facility Operations Manager 2 notified the Fire Safety Marshal and The Institutional Safety Manager that the door (c.) 15-18 was adjusted to be smoke tight on 5/30/24.

The Fire Safety Marshal followed up on 5/31/24 by physically checking the Dining Room doors 1080 and B-27 latching mechanisms were correctly working.

The Fire Safety Marshal followed up on 5/31/24 by physically checking door 15-18 to be smoke tight with the proper clearances per NFPA 80 and make sure the work was completed.


Monitors:
The Dining room and bedroom doors will be checked by the Fire Safety Marshal during the monthly building fire inspections. A deficiency will be noted in line item #16, "fire doors latch when closed", on the building inspection log and a work order will be generated by the Fire Safety Marshal to repair the latching mechanism and correct the doors that are not smoke tight.




NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie

Name - MAIN BUILDING 06 Component - 01
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in one location, affecting one of one floor.

Findings include:

1. Observation on May 23, 2024, at 9:40 a.m., revealed the 1038 smoke barrier separation door failed to close when released from the magnetic hold-open device, due to contact with the floor.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the smoke barrier door deficiency.




Plan of Correction:

The Corridor Door to Dayroom 1038 is used frequently. Normal wear and tear caused the top hinge screws of the door to become loose and making the door fall and hitting the ground.

The Facility Operations Supervisor created a work order # 24050223 on 05/23/24, to repair and adjust the corridor door to dayroom 1038 for the door to correctly latch and close by not hitting the floor. The door was adjusted and repaired on 05/24/24.

The Facility Operations Manager 2 notified the Fire Safety Marshal and The Institutional Safety Manager on 5/24/24, that the door 1038 was adjusted to latch and close not hitting floor and was adjusted and repaired.

The Fire Safety Marshal will follow up by physically checking the Corridor door to Dayroom door 1038 was adjusted and repaired to make sure the work was completed.

Monitors:
The Corridor door to Dayroom door 1038 will be checked by the Fire Safety Marshal during the monthly building fire inspections. A deficiency will be noted in line item #16, "fire doors latch when closed", on the building inspection log and a work order will be generated by the Fire Safety Marshal to repair the door to close.




Initial Comments:
Name - BUILDING 05 Component - 12

Facility ID # 55090100
Component 12
Building 05
Hilltop East

Based on an unannounced Medicare Recertification Survey completed May 22-23, 2024, it was determined that Clarks Summit State Hospital was not in compliance with the requirements of the Life Safety Code for an existing psychiatric 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 one story, Type II (000), unprotected, noncombustible building, with a full basement, that is fully sprinklered.




Plan of Correction:




NFPA 101 STANDARD
Vertical Openings - Enclosure

Name - BUILDING 05 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 vertical openings in two locations, affecting two of two floors.

Findings include:

1. Observation on May 23, 2024, between 11:12 a.m., and 11:23 a.m., revealed the following:

a. 11:12 a.m., the 2014 pipe chase door, and door frame assembly labels were painted over.
b. 11:23 a.m., the B-4 pipe chase door frame assembly lacked labeling.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the vertical opening deficiencies.




Plan of Correction:

The Pipe Chase doors (a.) 2014 and (b.) B-4 were painted, and Maintenance Repairmen 2 painted over the fire door labels on the frames. This caused the labels to be unseen for the proper ratings of the door frames to be seen.

The Facility Operations Supervisor created a work order on 05/23/24, to inspect the doors 2014 Work Order # 24050230 and B-4 Work Order # 24050231 to remove the paint from the door frame assembly labels. The door labels were found, and paint was cleaned off labels on doors (a.) 2014 on 05/24/24 and (b.) B-4 on 05/30/24.

The Facility Operations Manager 2 notified the Fire Safety Marshal and The Institutional Safety Manager on 5/30/24, that the door frame assembly labels on the frames were found and cleaned and to make sure the work was completed.

The Fire Safety Marshal followed up on 6/3/24 by physically checking the Pipe Chase doors to verify the labels were cleaned from paint and paint removed and labels are now able to be read.

Monitors:
The Pipe chase doors will be checked by the Fire Safety Marshal during the monthly building inspections and Annual fire door inspections. A deficiency will be noted in line item #16, "fire doors", on the building inspection log and a work order will be generated by the Fire Safety Marshal to clean the paint off the door frame assembly label.

Fire Marshal will complete a training and sign off sheet with the maintenance staff by 6/21/24. Training will cover when painting doors and door frames on Clarks Summit State Hospital buildings do not paint over the fire door assembly labels on the doors or the door frames. An opportunity for questions and answers will be provided.



NFPA 101 STANDARD
Corridor - Doors

Name - BUILDING 05 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 corridor openings in two locations, affecting one of two floors.

Findings include:

1. Observation on May 23, 2024, between 11:10 a.m., and 11:40 a.m., revealed the following:

a. 11:10 a.m., the second floor, Bedroom One door did not latch.
b. 11:40 a.m., the second floor, Special Care Room door was not smoke-tight.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the corridor opening deficiencies.





Plan of Correction:

The Second Floor Cube 1 Bedroom Door (a.) is used frequently. Normal wear and tear caused the door latching mechanism to fail and become loose and needs adjustments to become smoke tight.

The Facility Operations Supervisor created a work order on 05/23/24, to repair or replace the positive latching mechanism on door (a.) Second floor bedroom one door Work Order # 24050229. The latching mechanism was repaired on 05/31/24.

The Facility Operations Supervisor created a work order on 05/23/24, to repair the door that was not smoke tight on (b.) Special Care Room door # 2047 with Work Order # 24050232. The door was adjusted to be smoke tight on 05/29/24.

The Facility Operations Manager 2 notified the Fire Safety Marshal and The Institutional Safety Manager on 5/31/24 that the door latching mechanism was repaired on door (a.) Second Floor Bedroom Cube 1 and on 5/29/24 that (b.) Special Care Room door 2047 was adjusted to be smoke tight with the proper clearances per NFPA 80 and make sure the work was completed.

The Fire Safety Marshal followed up on 6/3/24 by physically checking the Second Floor Bedroom Cube 1 door latching mechanism and make sure the work was completed.

The Fire Safety Marshal followed up on 6/3/24 by physically checking door Special Care Room Door 2047 to be smoke tight with the proper clearances per NFPA 80 and make sure the work was completed.

Monitors:
The Second Floor Bedroom Cube 1 door and Second Floor Special Care Room door 2047 will be checked by the Fire Safety Marshal during the monthly building fire inspections and Fire Door Annual Inspection. A deficiency will be noted in line item #16, "fire doors latch when closed", on the building inspection log and a work orders will be generated by the Fire Safety Marshal to repair the latching mechanism and repair the door if not smoke tight.





Initial Comments:
Name - BUILDING 04 Component - 23

Facility ID # 55090100
Component 23
Building 04
Gateway House

Based on an unannounced Medicare Recertification Survey completed May 22-23, 2024, it was determined that Clarks Summit State Hospital was not in compliance with the requirements of the Life Safety Code for an existing psychiatric 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 building, with a basement, that is nonsprinklered.

There were no patients residing in Gateway House at the time of this survey.







Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - BUILDING 04 Component - 23
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 one location, affecting two of three floors.

Findings include:

1. Observation on May 22, 2024, at 9:55 a.m., revealed the Main Foyer stair treads compromised the integrity of the two-hour, floor slab assembly, located between basement and first floor levels.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the building construction deficiency.




Plan of Correction:

The Facility Operations Supervisor created a work order # 24050307 on 05/31/24, to construct and complete a fire barrier to meet the 2-hour fire rating to cover the stair treads.

The Facility Operations Supervisor and Facility Operations Manager 4 met with ORR Industries on Monday June 3, 2024, for a quote to apply a fire rated spray foam and Hilti Fire-Stop spray, to gain the 2-hour fire rating for the stair treads.

Clarks Summit State Hospital will work with DHS Division of Facilities and Property Management to develop a design using a tested fire rated assembly to achieve the required fire rating for this construction type. The design will be submitted to the DOH Division of Safety Inspection within 90 days.



NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste

Name - BUILDING 04 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 and interview, it was determined the facility failed to maintain the generator set in one instance, affecting three of three floors.

Findings include:

1. Observation on May 22, 2024, at 10:05 a.m., revealed the generator set lacked an externally-located, emergency stop/shut-off, switch/button.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the generator set deficiency.





Plan of Correction:

Quotes received for installation of emergency stop switches.

PO approval received on 5/31/24.

The Facility Operations Manager 4 and Life Safety Inspector observed there was no emergency stop button located externally mounted on the outside of the generator enclosure.

Electrician Supervisor notified Mechanical Services Company for a quote to add an external emergency stop button to the outside of the generator enclosure. Purchase Card order # 148627 that was approved by Accounting Department on 5/31/24 and Work Order # 24060014 entered on 06/03/24 by Electrician Supervisor.

Mechanical Services Company will complete the installation and testing of the emergency stop button by COB on June 14, 2024.



Initial Comments:
Name - BUILDING 02 Component - 45

Facility ID # 55090100
Component 45
Building 02
Newton Hall

Based on an unannounced Medicare Recertification Survey completed May 22-23, 2024, at Clarks Summit State Hospital, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing psychiatric 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 building, with a partial basement, that is partially sprinklered.

There were no patients residing in Newton Hall at the time of this survey.









Plan of Correction:




Initial Comments:
Name - BUILDING 03 Component - 56

Facility ID # 55090100
Component 56
Building 03
Summit Hall

Based on an unannounced Medicare Recertification Survey completed May 22-23, 2024, it was determined that Clarks Summit State Hospital was not in compliance with the requirements of the Life Safety Code for an existing psychiatric 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 building, with a basement, that is fully sprinklered.

There were no patients residing in Summit Hall at the time of this survey.






Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - BUILDING 03 Component - 56
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 one location, affecting one of three floors.

Findings include:

1. Observation on May 22, 2024, at 11:55 a.m., revealed the second floor Bathroom/Shower Room area structural steel, lacked fireproofing, located above the monolithic ceiling assembly.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the building construction deficiency.






Plan of Correction:

Clarks Summit State Hospital will work with DHS Division of Facilities and Property Management to develop a design using a tested fire rated assembly to achieve the required fire rating for this construction type. The design will be submitted to the DOH Division of Safety Inspection within 90 days.


NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste

Name - BUILDING 03 Component - 56
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 and interview, it was determined the facility failed to maintain the generator set in one instance, affecting three of three floors.

Findings include:

1. Observation on May 22, 2024, at 11:20 a.m., revealed the generator set lacked an externally-located, shut-off/stop, switch/button.

Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the generator set deficiency.





Plan of Correction:

Plan of Correction:

Quotes received for installation of emergency stop switches.

PO approval received on 5/31/24.

The Facility Operations Manager 4 and Life Safety Inspector observed there was no emergency stop button located externally mounted on the outside of the generator enclosure.

Electrician Supervisor notified Mechanical Services Company for a quote to add an external emergency stop button to the outside of the generator enclosure. Purchase Card order # 148627 that was approved by Accounting Department on 5/31/24 and Work Order # 24060013 entered on 06/03/24 by Electrician Supervisor.

Mechanical Services Company will complete the installation and testing of the emergency stop button by COB on June 14, 2024.