Initial Comments:
Name - ST. LUKE'S DIALYSIS QUAKERTOWN Component - 01
Facility ID# XMMT0101
Component 01
St. Luke's Quakertown Dialysis
Based on a Recertification Survey completed on August 22, 2022, it was determined that St. Luke's Quakertown Dialysis was not in compliance with the requirements of the Life Safety Code for an existing ESRD health care facility. Compliance with the National Fire Protection Association's Life Safety Code, is required by 42 CFR 494.60(e)(1).
This is a four story, Type II (222), fire resistive construction, (ground, first, second, and third floors, with a small penthouse), which is partially sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - ST. LUKE'S DIALYSIS QUAKERTOWN Component - 01
Building Construction Type and Height
Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively.
Construction Type
1 I (442), I (332), II (222), Any number of stories
II (111), III (211), IV (2HH), non-sprinklered or sprinklered
V (111)
2 II (000), III (200), V (000) One story non-sprinklered
Any number of stories sprinklered
Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met:
1. Such levels are under the control of the ambulatory health care occupancy.
2. Hazardous spaces are protected per section 8.7.
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively)
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.
20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain the rating of the floor/ceiling assembly, affecting two of four floors.
Findings include:
1. Observation on August 22, 2022, at 12:00 p.m., revealed there was an unsealed penetration, inside a four inch conduit, Electrical Room.
Exit Interview with the Director of Plant Operations on August 22, 2022, at 12:00 p.m., confirmed this unsealed penetration.
Plan of Correction:K 0161
On 08/22/22, the Director of Plant Operations was contacted and immediately and properly sealed the four (4) inch conduit in the floor/ceiling assembly located in the Electrical Room with fire resistant caulking. Ongoing compliance to verify all conduit penetrations are properly sealed, will be monitored monthly by the Director of Plant Operations or designee. Any unsealed penetrations noted will be immediately corrected. The Facility Administrator is responsible for compliance with this plan of correction.
Addendum: Please note: This plan of correction was revised to include all areas in BOLD on 09/09/22.
The penetration will be sealed with an approved UL stop gap penetrations system.
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - ST. LUKE'S DIALYSIS QUAKERTOWN Component - 01
Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7
Observations:
Based on observation and interview, it was determined the facility failed to ensure all rated, labeled doors met the standard of NFPA 80 2010 Edition, affecting one of four floors.
Findings include:
1. Observation on August 22 2022, between 11:50 a.m. and 12:30 p.m., revealed the following rated door deficiencies:
a. 11:50 a.m., Stairtower #3 door, had gaps greater than 3/16 inch;
b. 12:15 p.m., Workroom door, by the electrical room, was hitting the frame and did not close and latch;
c. 12:20 p.m., Workroom door, by the storage room, had gaps greater than 1/8 inch;
d. 12:30 p.m., fire rated door to the office, across from the storage room, had gaps greater than 1/8 inch.
Exit Interview with the Director of Plant Operations on August 22 2022, at 12:30 p.m., confirmed these rated door deficiencies.
Plan of Correction:The Facility Administrator met with door vendor on 08/26/22 to review needed door repairs: a. Stair tower door #3 gaps greater than 3/16 inch; b. Workroom door by electrical room hitting the frame and not closing/ latching; c. Workroom door by storage room had gaps greater than 3/16 inch; d. Fire rated door to the office, across from the storage room had gaps greater than 1/8 inch. All repairs are scheduled for completion by 10/15/22. Ongoing compliance of door closures will be monitored by the Director of Plant Operations: monthly with internal check and yearly by certified door and hardware vendor. Documentation of inspections will be stored and available to Facility Administrator upon request. The Facility Administrator is responsible for compliance with this Plan of Correction.
NFPA 101 STANDARD
Portable Fire Extinguishers
Name - ST. LUKE'S DIALYSIS QUAKERTOWN Component - 01
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10
Observations:
Based on document review and interview, it was determined the facility failed to maintain a current certificate for the annual fire extinguisher inspection.
Findings include:
1. Document review on August 15, 2022, between 1:00 p.m. and 2:00 p.m., revealed the facility failed to obtain a current certification certificate for the annual inspection in January 2022.
Exit Interview with the Director of Plant Operations on August 15, 2022, at 2:00 p.m., confirmed the lack of documentation.
Plan of Correction:The Facility Administrator immediately requested documentation for the annual fire extinguisher inspection which was completed in January 2022. Documentation was received on 08/23/22 and sent to the surveyor as proof of completion. Director of Plant Operations will request and receive inspector certification at the time of contract renewal. Documentation will be stored and available to the Facility Administrator upon request. The Facility Administrator is responsible for compliance with this plan of correction.
NFPA 101 STANDARD
Electrical Systems - Maintenance and Testing
Name - ST. LUKE'S DIALYSIS QUAKERTOWN Component - 01
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Based on document review and interview, the facility failed to inspect all receptacles in resident care areas throughout the facility.
Findings include:
Document review on August 22, 2022, between 1:00 p.m. and 2:00 p.m., revealed the facility lacked documentation verifying electrical receptacles were tested for the last 12 months.
Exit Interview with the Director of Plant Operations on August 15, 2022, at 2:00 p.m., confirmed the receptacles were not tested in the last 12 months.
Plan of Correction:The Facility Administrator immediately requested yearly electrical receptacle testing, which was completed by hospital engineering staff on 08/24/2022. The Director of Plant Operations will generate yearly Preventive Maintenance (PM) in maintenance management system for receptacle testing. PM results will be stored and available to the Facility Administrator upon request. The Facility Administrator is responsible for compliance with this plan of correction.
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