Titusville Area Hospital

“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: 49939 Based on observation and interview, the facility failed to maintain the fire barrier in one of over three hazardous areas. Findings include: Observation on September 16, 2025, at 12:18 p.m., revealed the soiled utility room on the second floor was intentionally blocked from closing and self-latching by a waste can. Interview with the maintenance supervisor on September 16, 2025, at 12:18 p.m., confirmed the door was intentionally blocked, preventing the self-closing door from closing and latching.”

“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 maintain portable fire extinguishers in one of two kitchens. Findings include: Observation on September 16, 2025, at 10:27 a.m., revealed the first-floor coffee shop food cooking area lacked a portable Class K fire extinguisher. Reference: NFPA 101 19.3.2.5 and NFPA 96 10.10 Interview with the maintenance supervisor on September 16, 2025, at 10:27 a.m., confirmed the Class K fire extinguisher was not present.”

“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 six of more than thirty electrical receptacles. Findings include: Observation on September 16, 2025, between 11:02 a.m. and 12:35 p.m., revealed the following electrical outlet deficiencies: 1. (11:02 a.m.) Laundry room had an unprotected receptacle located within six feet of a sink. The clothes washer was connected to a receptacle without ground fault circuit interrupter (GFCI) protection; 2. (11:24 a.m.) hand wash station located outside the operating room had a receptacle that was not GFCI-protected located within six feet of a water basin; 3. (11:30 a.m.) Nuclear med room had a hand sink with a receptacle that was not GFCI-protected located within six feet of a water basin; 4. (11:40 a.m.) Kitchen dirty side of dishwashing area had a receptacle that was not GFCI-protected located within six feet of a water basin; 5. (12:35 p.m.) Pharmacy had a hand sink with a receptacle that was not GFCI-protected located within six feet of a water basin. Interview with the maintenance supervisor on September 16, 2025, at 12:35 p.m., confirmed the electrical outlet deficiencies.”

“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: 43722 Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one diesel emergency generator. Findings include: Document review on September 16, 2025, at 10:37 a.m., revealed the annual vendor inspection found the jacket water heater outlet fitting was leaking coolant and needed replaced. The facility failed to provide documentation that the leak was fixed. Interview with the facilities manager on September 16, 2025, at 10:37 a.m., confirmed the corrective documentation was unavailable at the time of the survey.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must have written policies and procedures regarding the use of restraint and seclusion that are consistent with current standards of practice. This Standard is not met as evidenced by: 39272 Based on review of facility documentation and medical record review (MR), as well as employee interview (EMP), it was determined that the facility failed to follow its policy to complete a face-to-face assessment within one hour after the application of a restraint for one of one violent restraint records reviewed (MR14). Findings include: On September 4, 2025, review of the policy provided for restraint applications, revised July 2020, revealed, “... C. Restraints ... F. Orders for Restraint of the Patient for a Behavioral Reason ... c. The physician must perform a face-to-face assessment of the patient within one (1) hour of application of restraints and an order obtained. ...” 1. On September 3, 2025, review of MR14 revealed no documentation of a completed face-to-face assessment by the physician within one (1) after the application of restraints. This finding was confirmed by EMP1 at the time of the review.”