Geisinger-Bloomsburg Hospital

“Multiple Occupancies CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain one common wall, affecting one of three floors. Findings include: 1. Observation on November 25, 2024, at 12:33 p.m., revealed the first floor common wall door with the hospital occupancy required adjustment to fully latch. Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed the common wall deficiency.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain one exit stair tower enclosure in one location, affecting one of four floors. Findings include: 1. Observation on November 25, 2024, at 9:40 a.m., revealed penetration of the fourth floor portion of the east stair tower enclosure was filled with spackling material (located above the stair tower door). Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed stair tower enclosure deficiency.”

“Exit Signage CFR(s): NFPA 101 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.) This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain install and maintain exit signage in two locations, affecting one of four floors. Findings include: 1. Observation on November 25, 2024, between 9:50 a.m., and 9:53 a.m., revealed the following: a. 9:50 a.m., the exit sign chevron, located closest to the fourth floor, Elevator Lobby, pointed to the right, instead of left. b. 9:53 a.m., the fourth floor, Elevator Lobby area, lacked exit signage, pointing to the east stair tower enclosure. Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed exit signage deficiencies.”

“Corridor - Doors CFR(s): NFPA 101 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. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain corridor openings in three locations, affecting three of four floors. Findings include: 1. Observation on November 25, 2024, between 10:11 a.m., and 11:37 a.m., revealed the following: a. 10:11 a.m., the fourth floor, Examination Room 407 door was not smoke-tight. b. 10:14 a.m., the fourth floor, Room 413 door was not smoke-tight. c. 11:37 a.m., the second floor, east wing Data Closet door was not smoke-tight. Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed the corridor opening deficiencies.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 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. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain two smoke barrier separation walls, affecting one of four floors. Findings include: 1. Observation on November 25, 2024, between 11:38 a.m., and 11:44 a.m., revealed the following: a. 11:38 a.m., a penetration of the smoke barrier separation wall, above the doors, entering PACU. b. 11:44 a.m., the smoke barrier wall was not sealed between smoke barrier wall and fluted decking, located above the smoke barrier doors, at the top of the second floor ramp. Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed smoke barrier separation wall deficiencies.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain two smoke barrier separation doors, affecting two of four floors. Findings include: 1. Observation on November 25, 2024, between 11:29 a.m., and 11:40 a.m., revealed the following: a. 11:29 a.m., the smoke barrier separation door vision panels, located closest to the third floor A Elevators, lacked fire-rated glass and rated frame assemblies. b. 11:40 a.m., the second floor, “ramp” smoke barrier separation door’s panic hardware “end cap” was missing. Exit interview with the Facilities Manager on November 25, 2024, between 1:15 p.m., and 1:30 p.m., confirmed the smoke barrier separation door deficiencies.”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 48679 Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined one of fifteen personnel files did not include all required documents per the job description. (PF1) Findings include: Review on November 20, 2024, of the facility policy “BLS Training,” last reviewed on October 24, 2024, revealed: “Purpose To provide a mechanism to systematically monitor, evaluate and ensure Basic Life Support (BLS) training is current for employees as required by credentialing organizations or as required by department. Policy Employees ... must successfully complete BLS training consistent with Geisinger standards, at the time intervals designated below. Section 1 Employees - Clinical Care Licensed & Clinical Care Unlicensed ... New employees that have not completed BLS training and/or do not possess an American Heart Association BLS Provider eCard, have 60 days of the start date, or as required by department/credentialing organizations to obtain. ... “ Review on November 20, 2024, of Radiology Facilitator job description labeled “Geisinger overview” revealed “... Qualifications/Certifications required: Yes Basic Life Support Certification.” Review on November 20, 2024, of PF1 revealed a Radiology Facilitator job description, date of last change October 18, 2024. PF1 did not contain the required BLS (Basic Life Support) certification documentation. Interview with EMP5 on November 20, 2024, at approximately 1330 confirmed PF1 began the position of Radiology Facilitator on June 30, 2024. Interview with EMP5 on November 20, 2024, at approximately 1330 confirmed the above findings.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 32337 Based on observation, review of facility documents and staff interview (EMP), it was determined 1) the facility failed to ensure equipment and areas within the dietary department were cleaned per established cleaning schedules for ten of ten months reviewed (January 1, 2024 - October 31, 2024), and 2) the facility failed to ensure the medical/surgical unit flooring was maintained at an acceptable level of cleanliness and quality. Findings include: Review on November 20, 2024 of facility policy, “Cleaning and Sanitizing, Foodservice,” last reviewed January 29, 2024, revealed “Purpose To ensure food contact and non-food contact surfaces area cleaned and sanitized using Foodservice-approved cleaning agents, sanitizer, and methods. ... Policy The Foodservice department at each site is to have an effective cleaning program & schedule in place to ensure proper cleaning and sanitizing. This plan utilized the correct chemicals and procedures to keep food contact and non-food contact surfaces clean and sanitized. ...” Review on November 20, 2024, of the “Cooks Daily Cleaning Log,” revealed the inside ovens are to be cleaned every weekend. Review of this cleaning log for January 2024 revealed the inside ovens were not cleaned on January 13, 14, 27 or 28. Review of this cleaning log for February 2024 revealed the inside ovens were not cleaned on February 10, 11, 24 or 25. Review of this cleaning log for March 2024 revealed the inside ovens were not cleaned on March 9, or 10. Review of this cleaning log for May 2024 revealed the inside ovens were not cleaned on May 11 or 12. Review of this cleaning log for June 2024 revealed the inside ovens were not cleaned on June 15, 16, 29 or 30. Review of this cleaning log for August 2024 revealed the inside ovens were not cleaned on August 10 or 11. Review of this cleaning log for September 2024 revealed the inside ovens were not cleaned on September 7, 8, 21, or 22. Review on November 20, 2024, of the “Lead Daily Cleaning Log,” revealed the storeroom is to be cleaned every weekend. Review of this cleaning log for January 2024 revealed the storeroom was not cleaned on January 6, 7, 13 or 14. Review of this cleaning log for February 2024 revealed the storeroom was not cleaned on February 24 or 25. Review of this cleaning log for March 2024 revealed the storeroom was not cleaned on March 9, 10, 23 or 24. Review of this cleaning log for May 2024 revealed the storeroom was not cleaned on May 4, 5, 11,12, 18 or 19. Review of this cleaning log for June 2024 revealed the storeroom was not cleaned on June 1, 2, 8, 9, 15, 16, 29 or 30. Review of this cleaning log for July 2024 revealed the storeroom was not cleaned on July 6, 7, 13, 14, 20, 21, 27, or 28. Review of this cleaning log for August 2024, revealed the storeroom was not cleaned on August 10, 11, 17 or 18. Review of this cleaning log for September 2024 revealed the storeroom was not cleaned on September 7, 8, 14, 15, 21, 22, 28 or 29. Review on November 20, 2024, of the “Dishroom Daily Cleaning Log,” revealed the garbage cans, fridges on floors, and drains are to be cleaned every weekend. Review of this cleaning log for January 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on January 6, or 7. Review of this cleaning log for April 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on April 27 or 28. Review of this cleaning log for May 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on May 4, 5, 11, 12, 18 or 19. Review of this cleaning log for June 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on June 8, 9, 15, 16, 29 or 30. Review of this cleaning log for July revealed the garbage cans, fridges on floors, and drains were not cleaned on July 6, 7, 13, 14, 20, 21, 27 or 28. Review of this cleaning log for August 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on August 3, 4, 10, 11, 17, 18, 24 or 25. Review of this cleaning log for September 2024 revealed the garbage cans, fridges on floors, and drains were not cleaned on September 7, 8, 14, 15, 21, 22, 28 or 29. Review on November 20, 2024, of the “Cafe Daily Cleaning Log,” revealed the salad bar is to be cleaned every weekend. Review of this cleaning log for January 2024 revealed the salad bar was not cleaned on January 6, 7, 13, 14, 20, 21, 27 or 28. Review of this cleaning log for February 2024 revealed the salad bar was not cleaned on February 3, 4, 10, 11, 17, 18, 24 or 25. Review of this cleaning log for April 2024 reveal the salad bar was not cleaned on April 6, 7, 13, 14, 20, 21, 27 or 28. Review of this cleaning log for May 2024 revealed the salad bar was not cleaned on May 4, 5, 11, 12, 18, 19, 25 or 26. Review of this cleaning log for June 2024 revealed the salad bar was not cleaned on June 1, 2, 8, 9, 15, 16, 22, 23, 29 or 30. Review of this cleaning log for July 2024 revealed the salad bar was not cleaned on 6, 7, 13, 14, 20, 21, 27 or 28. Review of this cleaning log for August 2024 revealed the salad bar was not cleaned on August 3, 4, 10, 11, 17, 18, 24, 25, or 31. Review of this cleaning log for September 2024 revealed the salad bar was not cleaned on September 1, 7, 8, 14, 15, 21, 22, 28 or 29. Review of this cleaning log for October 2024 revealed the salad bar was not cleaned on October 12, 13, 19, 20, 26 or 27. Continued review of the “Cafe Daily Cleaning Log,” revealed 22 additional areas which are to be cleaned daily. Review of the 2024 log revealed there was no documentation these areas were cleaned on January 1, 6, 7, 13, 14, 20, 21, 27 and 28, February 3, 4, 10, 11, 17, 18, 24, and 25. March 2, 3, 9, 10, 16, 17, 23, 24, 30 and 31. April 6, 7, 13, 14, 20, 21, 27, and 28. May 4, 5, 12, 18, 19, 25, and 26. June 1, 2, 8, 9, 15, 16, 22, 23, 29 and 30. July 4, 6, 7, 13, 14, 20, 21, 27 and 28. August 3, 4, 10, 11, 17, 18, 24, 25, and 31. September 1, 2, 7, 8, 14, 15, 21, 22, 28, and 29. October 5, 6, 12, 13, 19, 20, 26 and 27. Interview with EMP4 on November 20, 2024, at 1030, confirmed the findings noted above for the Cooks Daily Cleaning Log, Lead Daily Cleaning Log, Dishroom Daily Cleaning Log, and the Cafe Daily Cleaning Log. EMP4 confirmed the weekend cleaning may be completed over two days, as it may take two days to complete the items listed, i.e. the two ovens. Interview with EMP8 on November 20, 2024, at 1445, confirmed the findings noted above for the Cooks Daily Cleaning Log, Lead Daily Cleaning Log, Dishroom Daily Cleaning Log, and the Cafe Daily Cleaning Log. 2) Tour and observation of the 3rd floor medical/surgical unit conducted with EMP2 and EMP3 on November 19, 2024, at 1425 revealed multiple grayish-black spots covering the flooring throughout the unit hallways. The laminate flooring was noted to be cracked and chipped away at the adjoining seams on the medical/surgical unit. Interview with EMP3 on November 19, 2024, at 1430 confirmed the above findings. EMP3 stated they suspect the hand sanitizer is causing the spots. Review of the “Infection Prevention and Control Plan, Surveillance, Risk Assessment and Goals” policy, last reviewed on July 31, 2024, revealed “... Cleaning and Disinfection for ... Environmental Surfaces GBH” [Geisinger- Bloomsburg Hospital] “staff, manager and designers select ... fixture surfaces that are made of nonabsorbable, non-porous materials that can be cleaned and disinfected following environmental cleaning and disinfection policies & guidelines. The practices and procedures promote and maintain a clean and sanitary environment that decreases environmental infection risk... EVS” [Environmental Services] “specific cleaning policies are in the Environmental Services manual located in Policy Manager, providing frequency, responsibilities, audit processes and procedures...” Review of “Environmental Services Scope of Services” policy, last reviewed on October 8, 2024, revealed “Purpose The purpose of the Environmental Services Department is to provide best in class and sustainable environmental services to our Patients, our Geisinger Family, and our community. ... The Environmental Services Department is a service-oriented department within Geisinger. Our mission is enhancing the quality of the healthcare environment ... Objectives: ... Utilize green cleaning chemicals and practices, when possible, without compromising cleanliness or infection control standards ... Services provided by the Environmental Services department include, but are not limited to: Provide routine cleaning services to all on campus buildings and peripheral areas (where applicable). In-Patient room cleaning & disinfection-occupied patient rooms-daily; discharge patient rooms as rooms are vacated. ... Floor care, to include stripping, waxing, buffing, and carpet extraction - scheduled and as needed. ...” A request was made on November 19, 2024 at 1440, to EMP2 for the 3rd floor medical/surgical unit scheduled floor cleaning. Review on November 20, 2024, at 0910, of the floor cleaning schedule from July - November 2024, provided by EMP6, revealed documentation of weekly cleaning/scrubbing of the 3rd floor medical/surgical unit flooring. Interview with EMP7 on November 20, 2024, at 1450 indicated leadership was aware of the condition of the floor. The flooring was unable to be replaced due to budget constraints.”