Punxsutawney Area Hospital

“Building Rehabilitation CFR(s): NFPA 101 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) This Standard is not met as evidenced by: 42642 Based on observation and interview, the facilty failed to meet building rehabilitation requirements for one of one generator. Findings include: Interview on March 14, 2024, at 11:10 a.m., revealed the facility upgraded the generator control and annunciator panel in October 2023. No state plan approval was submitted prior to the upgrade, nor was an occupancy inspection granted by the Division of Life Safety. The facility is currently waiting on engineer drawings for the project. Interview with the facilities director on March 14, 2024, at 11:10 a.m., confirmed the unapproved upgrades.”

“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: 42642 Based on observation and interview, the facility failed means of egress requirements for one of over five exits. Findings include: Observation on March 14, 2024, at 10:11 a.m., revealed the emergency exit next to the MRI was blocked by contruction barriers. Interview with the director of facilities on March 14, 2024, at 10:11 a.m., confirmed the emergency exit was blocked.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain emergency lighting, affecting one of three building components. Findings include: Observation on March 14, 2024, at 11:41 a.m., revealed the battery back-up emergency light in the sterile processing room did not illuminate when the test button was pushed. Interview with the maintenance technician on March 14, 2024, at 11:41 a.m., confirmed the emergency light 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: 49939 Based on observation and interview, the facility failed to maintain exit signs for five of over twenty emergency exits. Findings include: Observation on March 14, 2024, between 10:00 a.m. and 11:10 a.m., revealed the following exit sign deficiencies: A. (10:00 a.m.) Main floor, two doors out of three leading to enclosed courtyards failed to display “No Exit” signs; B. (10:32 a.m.) Main floor, purchasing room B-112 discharge door failed to display an exit sign; C. (11:07 a.m.) Main floor, conflicting directional signage was posted at rear interior entrance to the emergency room; D. (11:10 a.m.) Main floor, exit sign was visually obscured on the exit path near the radiology entrance; E. (11:43 a.m.) Main floor, fire doors were missing an exit sign near the house instrumentation pick-up room. Interview with the maintenance technician on March 14, 2024, at 11:43 a.m., confirmed the exit sign deficiencies.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet alcohol-based hand rub dispenser (ABHR) requirements in one of over twenty exam rooms. Findings include: Observation on March 14, 2024, at 10:44 a.m., revealed the second floor suite 2300 had an ABHR mounted directly over an electrical outlet. Interview with the director of facilities on March 14, 2024 at 10:44 a.m., confirmed the 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: 42642 1. Based on document review and interview, the facility failed to meet fire alarm system testing and maintenance requirements for one of one system. Findings include: Document review on March 14, 2024, at 9:20 a.m., revealed the facility fire alarm system inspection, completed July 27, 2023, lacked the inspection of over 17 components, which included pull stations, smoke detectors, and duct detectors. The facility was unable to provide documentation that these components were tested within the last year. Interview with the director of facilities on March 14, 2024, at 9:20 a.m., confirmed the deficiency existed. 2. Based on observation and interview, the facility failed to maintain fire alarm systems in one of twelve smoke compartments. Findings include: Observation on March 14, 2024, at 10.32 a.m., revealed the fire alarm pull station notification device was obstructed by a cart in the purchasing room located by the exit discharge door. Device obstruction could delay manual alarm system activation. An interview with the maintenance technician on March 14, 2024, at 10.32 a.m., confirmed the fire alarm device was obstructed.”

“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: 49939 Based on observation and interview, the facility failed to maintain the sprinkler system in one of twelve smoke compartments. Findings include: Observation on March 14, 2024, at 11:59 a.m., revealed the first-floor kitchen storage room had a loose escutcheon plate that created an opening in the ceiling, potentially causing a delay in sprinkler activation. Interview with the maintenance technician on March 14, 2024, at 11:59 a.m., confirmed the sprinkler escutcheon plate was not properly installed.”

“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: 49939 Based on observation and interview, the facility failed to provide portable fire extinguishers in two of over fifty rooms. Findings include: Observation on March 14, 2024, at 10:10 a.m. and 10:32 a.m., revealed the following discrepancies: A. (10:10 a.m.) Main floor respiratory department had no portable fire extinguisher installed. Ref: NFPA 10 -6.2.1.2 B. (10:32 a.m.) Main floor purchasing room fire extinguisher was not readily accessible, visually obstructed by staged boxes and a cart. Interview with the maintenance technician on March 14, 2024, at 10:10 a.m., confirmed the 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: 49939 Based on observation and interview, the facility failed to maintain smoke barrier requirements on one of one building level. Findings include: Observation on March 14, 2024, between 10:05 a.m., and 12:06 p.m., revealed the following deficiencies: A. (10:05 a.m.-12:06 p.m.) Main floor smoke and fire dampers could not be identified from the underside of the ceiling tiles. Ref: NFPA 90A -6.3.1.2; B. (10:05 a.m.-12:06 p.m.) Main floor ceiling tiles lacked maintenance, with loose, misaligned, broken, and missing tiles present, which would allow smoke passage throughout the facility. C. (11:50 a.m.) Main floor, above the double doors near the house instrumentation pick-up room, revealed a penetration through the wall not sealed with fire caulk. Interview with the maintenance supervisor on February 29, 2024, at 10:52 a.m., confirmed the smoke barrier deficiency.”

“Soiled Linen and Trash Containers CFR(s): NFPA 101 Soiled Linen and Trash Containers Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain soiled linen/trash quantities in one of more than ten soiled linen/trash rooms. Findings include: Observation on March 14, 2024, at 11:01 a.m., revealed soiled linen/trash on the floor, creating a fire hazard. Interview with the maintenance technician on March 14, 2024, at 12:02 p.m., confirmed the deficiency.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 42642 Based on document review and interview, the facility failed to meet gas and vacuum-piped system requirements for one of one system. Findings include: Document review on March 14, 2024, between 9:50 a.m. and 10:01 a.m., revealed the following system deficiencies, documented on the March 9, 2023 inspection report, lacked corrective documentation: A. (9:50 a.m.) Outdoor bulk pad lacked a demand pressure switch; B. (9:51 a.m.) Outdoor bulk pad emergency 02 connection was not present; C. (9:51 a.m.) Outdoor bulk pad main line gaug wase not present; D. (9:52 a.m.) Mechanical room carbon monoxide monitor was not accurate; E. (9:53 a.m.) Mechanical room had no main line vacuum switch or gauge present; F. (9:54 a.m.) Mechanical room source valve was not tagged and discharge piping was not labeled; G. (9:56 a.m.) Mechanical room exhaust was not turn down screened or protected; H. (9:56 a.m.) Manifold room pigtails were out of date; I. (9:56 a.m.) Manifold room manifold was obsolete; J. (9:56 a.m.) Manifold location was non-compliant; K. (9:57 a.m.) Manifold room had no demand check on pressure switch; L (10:01 a.m.) Floor 1C nurse station panel model was not compliant and needed replaced. Interview with the facilities director on March 14, 2024, at 10:01 a.m., confirmed the deficiencies did not have corrective documentation at the time of the survey.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain electrical systems for one of over five electrical rooms. Findings include: Observation on March 14, 2024, at 11:01 a.m., revealed the emergency room storage had boxes in front of the electrical panels, preventing access. Interview with the maintenance technician on March 14, 2024, at 11:10 a.m., confirmed the items were blocking the electrical panels at the time of the survey.”

“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: 49939 Based on observation and interview, the facility failed to maintain electrical receptacles on one of two building levels. Findings include: Observation on March 14, 2024, between 10:27 a.m. and 12:05 a.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection within six feet of sinks and water sources in the following locations: A. (10:27 a.m.) Main floor kitchen, women’s restroom; B. (10:37 a.m.) Main floor operating room, break room; C. (10:48 a.m.) Main floor histology room, workstation strip multi outlets; D. (10:53 a.m.) Main floor laboratory, workstation strip outlets; E. (10:58 a.m.) Main floor laboratory, cleaning sink; F. (11:13 a.m.) Main floor x-ray room 3; G. (11:15 a.m.) Main floor x-ray room 1; H (11:20 a.m.) Main floor SPU, nurses station; I. (11:24 a.m.) Main floor SPU, recovery room, bed 11; J. (11:26 a.m.) Main floor sterile utility, hopper room; K. (11:29 a.m.) Main floor emergency room, men’s locker room; L. (11:58 a.m.) Main floor emergency room, soiled laundry room; M. (12:00 p.m.) Main floor soiled utility room, across from room C-122; N (12:05 p.m.) Main floor ICU department, nourishment room, ice machine. Interview with the maintenance technician on March 14, 2024, at 12:05 p.m., confirmed the electrical deficiencies.”