QA Investigation Results

Pennsylvania Department of Health
DANVILLE STATE HOSPITAL
Building Inspection Results

DANVILLE STATE HOSPITAL
Building Inspection Results For:


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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on December 14, 2023, at Danville State Hospital, it was determined there were no deficiencies identified with the requirements of 42 CFR 482.15.




Plan of Correction:




Initial Comments:
Name - BUILDING 3 Component - 78

Facility ID# 56100100
Component 78
Building 03
North Block Building

Based on an unannounced Medicare Recertification Survey completed December 14, 2023, it was determined that Danville State Hospital was not in compliance with the requirements of the Life Safety Code an existing acute care 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 III (211) protected, ordinary building, with attic and basement, that is fully sprinklered.




Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - BUILDING 3 Component - 78
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, affecting four of four floors within this component.

Findings include:

1. Observation on December 14, 2023, between 8:30 a.m., and 11:30 a.m., revealed this component exceeded the maximum allowable story height for this type of construction.

Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed this component exceeded the maximum allowable story height for this type of construction.





Plan of Correction:

Danville State Hospital is requesting an updated FSES from the Department of Health.


NFPA 101 STANDARD
Exit Signage

Name - BUILDING 3 Component - 78
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 maintain exit signage in one location, affecting one of four floors.

Findings include:

1. Observation on December 14, 2023, at 9:14 a.m., revealed exit signage had been removed from the second floor, Unit 214 construction area.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the exit signage deficiency.




Plan of Correction:

Danville State Hospital reinstalled the exiting signage. Integrity of the exiting and directional signage will be checked, and deficiencies documented on monthly risk rounds.


NFPA 101 STANDARD
Vertical Openings - Enclosure

Name - BUILDING 3 Component - 78
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 three locations, affecting three of three floors.

Findings include:

1. Observation on December 14, 2023, between 10:23 a.m., and 10:42 a.m., revealed the following:

a. 10:23 a.m., a penetration of the floor slab assembly, located within the third floor room, closest to stair tower door 3072.
b. 10:40 a.m., at the floor slab assembly, located within the Unit 209 Shower Room.
c. 10:42 a.m., an unprotected, three story, vertical opening, located within the Unit 209 Shower Room.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the vertical opening deficiencies.




Plan of Correction:

Danville State Hospital installed UL Listed 3M Fire Barrier Plastic Pipe Device. The integrity of the penetration will be checked on the monthly Penetrations check Preventative Maintenance Work Order.


NFPA 101 STANDARD
Hazardous Areas - Enclosure

Name - BUILDING 3 Component - 78
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)

Observations:

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of four floors.

Findings include:

1. Observation on December 14, 2023, at 9:02 a.m., revealed the Unit 211, Room 1100F, Janitor's Closet door lacked a self-closing device.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the hazardous area enclosure deficiency.




Plan of Correction:

Danville State Hospital installed self-closing device. Integrity of the self-closing devices in hazardous areas will be checked, and deficiencies documented on monthly risk rounds.


NFPA 101 STANDARD
Sprinkler System - Installation

Name - BUILDING 3 Component - 78
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:

Based on observation and interview, it was determined the facility failed to install automatic sprinkler protection in one location, affecting one of four floors.

Findings include:

1. Observation on December 14, 2023, at 8:37 a.m., revealed the Unit 211, electrical closet, lacked automatic sprinkler protection.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed automatic sprinkler protection deficiency.




Plan of Correction:

Danville State Hospital installed automatic sprinkler protection to Unit 211 Electrical Closet. The integrity of the automatic sprinkler system will be checked, and deficiencies documented on monthly risk rounds.


NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie

Name - BUILDING 3 Component - 78
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 maintain smoke barrier walls in two locations, affecting two of four floors.

Findings include:

1. Observation on December 14, 2023, between 9:31 a.m., and 10:10 a.m., revealed penetrations of the smoke barrier separation walls in the following locations:

a. 9:31 a.m., within the second floor, Unit 213, above the 2016 door.
b. 10:10 a.m., above third floor, smoke barrier door 3300.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the smoke barrier separation wall deficiencies.





Plan of Correction:

Danville State Hospital installed UL Listed Spec Seal Firestop Pillow until project is complete and then UL listed 3M Fire Barrier Moldable Putty will be used.

Danville State Hospital installed UL Listed Spec Seal Firestop Pillow until project is complete and then UL listed 3M Fire Barrier Moldable Putty will be used.

The integrity of the penetrations will be checked on the monthly Penetrations check Preventative Maintenance Work Order.




NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie

Name - BUILDING 3 Component - 78
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 one set of smoke barrier separation doors, affecting one of four floors.

Findings include:

1. Observation on December 14, 2023, at 9:22 a.m., revealed the 2200A, smoke barrier separation door, was lacking a portion of the self-closing assembly.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the smoke barrier separation door deficiency.




Plan of Correction:

Danville State Hospital installed missing cover to self-closing device.

The integrity of the self-closing device will be checked, and deficiencies documented on monthly risk rounds.


NFPA 101 STANDARD
HVAC

Name - BUILDING 3 Component - 78
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 the heating, ventilation, and air conditioning system in one location, affecting two of four floors.

Findings include:

1. Observation on December 14, 2023, at 8:45 a.m., revealed a fresh air duct penetration of the floor slab assembly, located within the first floor, Unit 211, Room 1100C, lacked retaining angles and a fire damper.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the HVAC deficiency.




Plan of Correction:

Danville State Hospital will install a UL listed Type C Fire Damper and UL listed SMACNA E class retaining angles.

The integrity of the fire damper will be checked and documented on the Fire Damper Preventative Maintenance Work Order.


Initial Comments:
Name - BUILDING 2 Component - 89

Facility ID# 56100100
Component 89
Building 02
South Block Building

Based on an unannounced Medicare Recertification Survey completed December 14, 2023, it was determined that Danville State Hospital was not in compliance with the requirements of the Life Safety Code an existing acute care 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 III (211) protected, ordinary building, with attic and basement, that is fully sprinklered.



Plan of Correction:




NFPA 101 STANDARD
Multiple Occupancies

Name - BUILDING 2 Component - 89
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:

Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of four floors.

Findings include:

1. Observation on December 14, 2023, at 11:40 a.m., revealed the Unit 311, Visiting Room door required adjustment to fully latch within the door frame assembly.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the common wall door deficiency.




Plan of Correction:

Danville State Hospital Adjusted closer on Work Order # 23120195.

The integrity of the self-closing device will be checked, and deficiencies documented on monthly risk rounds.


NFPA 101 STANDARD
Building Construction Type and Height

Name - BUILDING 2 Component - 89
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, affecting four of four floors within this component.

Findings include:

1. Observation on December 14, 2023, between 11:30 a.m., and 1:15 p.m., revealed this component exceeded the maximum allowable story height for this type of construction.

Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed this component exceeded the maximum allowable story height for this type of construction.




Plan of Correction:

Danville State Hospital is requesting an updated FSES from the Department of Health.


NFPA 101 STANDARD
Stairways and Smokeproof Enclosures

Name - BUILDING 2 Component - 89
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 one stair tower enclosure, affecting three of three floors.

Findings include:

1. Observation on December 14, 2023, at 12:44 p.m., revealed the Unit 214, door 2055, stair tower enclosure door was not fire-tight.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the stair tower deficiency.




Plan of Correction:

Danville State Hospital will repair existing door or replace with 90-minute rated door.


NFPA 101 STANDARD
Vertical Openings - Enclosure

Name - BUILDING 2 Component - 89
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 one vertical opening, affecting two of four floors.

Findings include:

1. Observation on December 14, 2023, at 11:50 a.m, revealed a vertical penetration of the floor slab assembly, located within the 310 Unit, Room 1244.


Exit interview with the Facility C.E.O., the Facility Executive Director, and the Facilities Manager, on December 14, 2023, between 1:15 p.m., and 1:30 p.m., confirmed the vertical opening deficiency.




Plan of Correction:

Danville State Hospital installed UL Listed Spec Seal Firestop Pillow until project is complete and then UL listed 3M Fire Barrier Moldable Putty will be used.

The integrity of the penetration will be checked on the monthly Penetrations check Preventative Maintenance Work Order.