Chan Soon- Shiong Medical Center at Windber

“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: 41378 Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the healthcare occupancy from other occupancies in two instances, affecting the entire facility. Findings include: 1. Observation on October 16, 2024, revealed the following two-hour occupancy separation deficiencies: a) 9:13 a.m., observation above the occupancy separation doors, at occupational therapy on the fourth floor, revealed multiple unsealed data wires were passing through a conduit in the occupancy separation wall; b) 10:06 a.m., observation above the occupancy separation doors, at Center for Life on the fifth floor, revealed multiple unsealed data wires were passing through a conduit in the occupancy separation wall. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed two-hour occupancy separation deficiencies.”

“Means of Egress - General CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain exit access in one instance, affecting exiting in two of eleven smoke compartments. Finding included: 1. Observation on October 15, 2024, at 11:17 a.m., revealed the second-floor stairwell by the Helipad was not in compliance with NFPA 101 section 7.7.3. The exit discharge for the stairway is located on the second floor and the stairs continue uninterrupted to the first floor. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed exit access deficiency.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain self-closing doors in one instance, affecting one of eleven smoke compartments. Findings include: 1. Observation on October 15, 2024, at 9:56 a.m., revealed the arm was removed from the self-closing device on the pharmacy door leaving the door unable to self-close when tested. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed self-closing door deficiency.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 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. This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain vertical opening enclosures in one instance, affecting two of eleven smoke compartments. Findings include: 1. Observation on October 15, 2024, at 11:28 a.m. revealed the Wing Three stairwell, near the elevators on the second floor, had multiple unsealed pipe penetrations in the front wall above the door. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the vertical opening enclosure deficiency.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 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) This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of eight smoke compartments. Findings include: 1. Observation on October 16, 2024, at 9:29 a.m., revealed the facility failed to maintain the required one-hour fire rating in the elevator equipment room, in the locker room hallway, on the fourth floor. There was an unsealed pipe penetration in the wall behind the elevator hydraulic pump. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed hazardous area enclosure deficiency.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 41378 Based on documentation review and interview it was determined the facility failed to perform the required semi-annual visual fire alarm system inspection, affecting the entire facility. Findings Include: 1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility failed to perform the required semi-annual visual fire alarm system inspection. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed fire alarm system inspection deficiency.”

“Sprinkler System - Supervisory Signals CFR(s): NFPA 101 Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72 This Standard is not met as evidenced by: 41378 Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting the entire facility. Testing shall be in accordance with NFPA 72...14.4.5. Number 15 L (1) and (M) Findings include: 1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility failed to perform the following required semi-annual inspection/testing of the automatic sprinkler system: a) valve supervisory switches/tamper switch (semi-annual) 14.4.5, initiating devices (1); b) vane and pressure switch water-flow alarm devices (semi-annual) 14.4.5 initiating devices (m). Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed valve supervisory switch and water flow alarm deficiencies.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 41378 Based on documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in eight instances, affecting the entire facility. Findings include: 1. Observation on October 15, 2024, revealed the following automatic sprinkler system deficiencies: The facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system in the following locations: a) 10:06 a.m., there were multiple unsealed wire and pipe penetrations in the ceiling of the old security office; b) 10:09 a.m., there were multiple unsealed pipe penetrations in the ceiling of the utility closet by the pharmacy window; c) 10:19 a.m., there were multiple unsealed pipe penetrations in the ceiling of the transformer room by the ED; d) 11:01 a.m., there were multiple unsealed wire penetrations in the ceiling of the Cath Lab electrical closet located on the second floor; e) 11:11 a.m., there were multiple wires on the sprinkler branch line, above the ceiling, by the Wing Three equipment room on the second floor. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies. 2. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the following automatic sprinkler system inspection and testing deficiencies: a) the facility failed to perform the required annual and semi-annual sprinkler system inspections in the past twelve months; b) the facility failed to provide documentation for the required five-year internal inspection and the replacement or recalibration of gages for the automatic sprinkler system; c) the facility failed to perform the required annual fire pump inspection within the past twelve months. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 41378 Based on observation, documentation review, and interview, it was determined the facility failed to maintain portable fire extinguishers in three instances, affecting the entire facility. In accordance with NFPA 10, 7.1.2.1. Findings include: 1. Observation on October 15, 2024, at 11:45 a.m., revealed the portable fire extinguisher in the boiler room hallway was sitting on the floor unsecured. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the portable fire extinguisher was on the floor and unsecured. 2. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the following portable fire extinguisher inspection deficiencies: a) the facility failed to provide an annual portable fire extinguisher report; b) the facility is unable to confirm if the person/persons who performed the annual portable fire extinguisher inspection are certified to inspect portable fire extinguishers. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed portable fire extinguisher maintenance and inspection 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: 41378 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of eight smoke compartments. Findings include: 1. Observation on October 16, 2024, at 9:45 a.m., revealed there were unsealed MC cables in the smoke barrier wall inside OBGYN exam room 6, above the door. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed smoke barrier wall deficiency.”

“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: 41378 Based on observation and interview, it was determined the facility failed to maintain self-closing smoke barrier doors with a coordinating device, in two instances, affecting two of eight smoke compartments. In accordance with NFPA 80, 2010 Edition, 6.4.1.2 and 6.4.1.2.1. Findings include: 1. Observation on October 16, 2024, revealed the following smoke doors were equipped with an astragal, preventing the inactive door from closing and latching before the active door closes and latches, suggesting coordinating devices shall be used. a) 10:10 a.m., the smoke barrier doors located in PT by Center for Life; b) 10:27 a.m., the smoke barrier doors located in PT by Hospice. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed smoke barrier door deficiencies.”

“HVAC CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 41378 Based on documentation review and interview, it was determined the facility failed to ensure smoke dampers were inspected within the required six-year period, affecting eight of eight smoke compartments in the facility. In accordance with NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives. Findings include: 1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility lacked documentation to indicate that smoke dampers were inspected every six years. There is no documentation available to confirm smoke damper inspection was performed within the required six-year period. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed smoke damper deficiency.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 41378 Based on documentation review and interview, it was determined the facility failed to perform four of 12 required fire drills. Findings include: 1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility failed to perform the following required fire drills: a) third shift in the first quarter of the year; b) second shift in the second quarter of the year; c) second shift in the fourth quarter of the year; d) third shift in the fourth quarter of the year. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed fire drill deficiencies.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in two instances, affecting two of eleven smoke compartments. Findings include: 1. Observation on October 15, 2024, revealed the following electrical receptacles, within six feet of a sink, were not GFCI-protected: a) 9:53 a.m., in the Pharmacy; b) 10:31 a.m., in the staff lounge located in the Lab. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the above-listed electrical receptacle deficiency.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 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) This Standard is not met as evidenced by: 41378 Based on documentation review and interview, it was determined the facility failed to maintain the automatic transfer switch, in one instance, affecting the entire facility. Testing shall be in accordance with NFPA 110, 8.4.6. and NFPA 101 7.9.1.3. Findings include: 1. Review of documentation on October 17, 2024, at 9:30 a.m., revealed the facility failed to perform and document the required monthly testing/function of the automatic transfer switch, to confirm a delay of not more than ten seconds is permitted to switch to emergency power. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed automatic transfer switch testing/function deficiency.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of eleven smoke compartments. Findings include: 1. Observation on October 15, 2024, at 9:58 a.m., revealed a microwave plugged into a power strip in patient registration room one. Interview with the Maintenance Director and Maintenance Staff on October 17, 2024, at 1:30 p.m., confirmed the listed electrical wiring systems deficiency.”

“ELIGIBILITY & PROCESS FOR APPT TO MED STAFF CFR(s): 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope of practice laws, the medical staff may also include other categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are determined to be eligible for appointment by the governing body. This Standard is not met as evidenced by: 29411 Based on review of facility documents, credential files (CF) and interview with facility staff (EMP) it was determined that the facility failed to follow adopted bylaws by failing to ensure that medical staff and allied health professionals were credentialed/privileged to practice in five of 10 credential files (CF1, CF2, CF3, CF4 and CF5). Findings include: Review of “Bylaws of the Medical Staff of Windber Medical Center” dated October 4, 2023, revealed, “... Definitions ... 6) Clinical Privileges or Privileges-Duty or permission to independently provide medical or other patient care services in the Medical Center. When an individual has clinical privileges, that individual shall have full and unrestricted access to those hospital resources which are reasonably necessary to the full exercise of the privileges, including but not limited to, all necessary hospital equipment, facilities, and personnel, except to the extent such access is limited by a restriction on the privileges imposed in accordance with these Bylaws. ... Part B. Section 1. Duration of Initial Provisional Appointment ... All initial appointments to the Medical Staff, regardless of the staff category and all initial clinical privileges are provisional from the date of the appointment until the board has acted upon a recommendation to grant or not to grant a regular appointment. At the end of the initial six-month provisional period, the practitioner’s activity will be assessed. If the practitioner’s clinical activity has not been sufficient upon which to make a determination, the provisional period may be extended to a total of 24 months (to allow for the aggregation of sufficient data on clinical activity). The appointment is then provisional up to 24 months from the initial date of appointment until the board has acted upon a recommendation to grant or not to grant a regular appointment. ... .” Review of credential file (CF1) Board of Directors most current reappointment letter dated July 7, 2022, revealed, “... You have been granted Allied Health Professionals Staff, Category I A (Independent Practitioner) privileges from 7/6/2022-6/30/2024. ... .” Review of credential file (CF2) Board of Directors most current reappointment letter dated July 7, 2022, revealed, “... You have been granted Active Medical Staff privileges in the Department of Surgery-Anesthesia, from 7/6/2022 thru 6/30/2024. ... .” Review of credential file (CF3) Board of Directors most current reappointment letter dated January 10, 2023, revealed, “... Provisional privileges are granted from 1/4/2023 to 1/4/2024 (always 12 months. ... .” Review of credential file (CF4) Board of Directors most current reappointment letter dated October 7, 2022, revealed, “... You have been granted Allied Health Professionals Staff, Category II A privileges as a Certified Physician Assistant from 10/5/2022 to 9/30/2024. ... .” Review of credential file (CF5) Board of Directors most current reappointment letter dated September 8, 2023, revealed, “... You have been granted provisional active privileges in the Department of Surgery. Your provisional privileges are granted from 9/6/2023 to 9/6/2024, (always 12 months). ... .” Interview with EMP3 and EMP4 on October 3, 2024, confirmed the above medical staff and allied health professionals lapsed in their stated appointment/reappointment and continued to attend patients.”

“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: 29411 Based on review of facitlty documents and interview with facility staff (EMP) it was determined that the facility failed to ensure safe practices by failing conduct quarterly fire drills at its provider-based satellite clinics in three of eight clinics. Findings include: Request was made by surveyor to review the last four quarterly fire drills for the facility’s provider-based satellite clinics on October 1, 2024. Review of facility documentation entitled, “Educational Inservice Sign-In Sheets ... Program Title: Fire Drill off Site Draw Stations ... Fire drill performed by: ...” failed to reveal documention that a fire drill was conducted quarterly in three of eight locations. Interview with EMP1 on October 3, 2024, confirmed the above finding.”