Penn Highlands Elk

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General 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. This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the entire facility. Findings include: Document review on April 30, 2024, at 10:30 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey. The Life Safety Code Floor Plan shall include the following: a. Smoke barrier walls (outside wall to outside wall); b. Fire barrier walls (1-2 hour walls); c. Horizontal exits; d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility’s responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan; e. Required exits should be clearly noted; f. Shaft walls. Interview with the maintenance supervisor on April 30, 2024, at 10:30 a.m., confirmed the facility’s Life Safety Code Floor Plan was unavailable at the time of the survey.”

“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 six of over fifty exit signs. Findings include: 1. Observation on April 30, 2024, at 1:35 p.m., revealed the third floor smoke barrier doors, located next to the elevator lobby, had a missing exit sign above the doors. Interview with the maintenance supervisor on April 30, 2024, at 1:35 p.m., confirmed the deficiency. 2. Observation on May 1, 2024, between 10:38 a.m. and 12:09 p.m., revealed the following exit sign deficiencies: A. (10:38 a.m.) Ground floor break room, laboratory door to corridor, had a missing exit sign; B. (11:14 a.m.) Ground floor smoke barrier door in x-ray department had a missing exit sign above the door; C. (11:16 a.m.) Ground floor directional exit sign was missing near the entrance to the emergency room; D. (12:02 p.m.) Ground floor smoke barrier doors, labeled “To Education Center,” had a missing exit sign above the door; E. (12:09 p.m.) Ground floor corridor from elevator seven, lobby to the x-ray department, had a missing exit sign above the door. Interview with the maintenance supervisor on May 1, 2024, at 12:09 a.m., confirmed the exit sign 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: 49939 Based on observation and interview, the facility failed to maintain the automatic sprinkler system for two of two building components. Findings include: Observation on May 1, 2024, at 10:56 a.m., revealed the sprinkler flow alarm switch, located on the sprinkler main, was missing the electrical protection cover. The electrical cover is necessary for circuit protection, and left unprotected, could lead to system malfunctions. Interview with the maintenance supervisor on May 1, 2024, at 10:56 a.m., confirmed the missing cover on the water flow alarm device.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain information and warning signs for gas and vacuum piped systems in two of over fifty rooms. Findings include: Observation on May 1, 2024, between 10:34 a.m. and 10:53 a.m., revealed the following deficiencies; A. (10:34 a.m.) Ground floor, above smoke door near the pharmacy, had an unlabeled gas/vacuum line at the wall penetration above the lay-in ceiling tiles. B. (10:53 a.m.) Ground floor mechanical room, in the ceiling above the man door, had an unlabeled gas/vacuum line at the wall penetration. Interview with the maintenance supervisor on May 1, 2024, at 10:53 a.m., confirmed the piped systems were not labeled 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 in nine of over fifty rooms. Findings include: Observation on May 1, 2024, between 10:40 a.m. and 12:28 p.m., revealed the facility failed to ensure electrical ground fault circuit interrupter (GFCI) protection within six feet of sinks in the following locations: A. (10:40 a.m.) Ground floor histology lab; B. (10:41 a.m.) Ground floor glassware washroom; C. (10:43 a.m.) Ground floor micro-bio room; D. (11:06 a.m.) Ground floor mechanical room; E. (11:27 a.m.) Ground floor monogram dressing room; F. (11:41 a.m.) Ground floor emergency room, ice and water machine; G. (12:17 p.m.) First floor sleep lab, bathroom; H. (12:23 p.m.) First floor SPU ice machine, near recovery room; I. (12:28 p.m.) First floor SPU, break room. Interview with the maintenance supervisor on May 1, 2024, at 12:28 p.m., confirmed the electrical outlet deficiencies.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain gas equipment storage requirements on one of three building levels. Findings include: Observation on May 1, 2024, at 11:37 a.m., revealed an unsecured oxygen tank in the emergency department corridor on the ground floor. The deficiency was corrected at the time of the survey. An interview with the maintenance supervisor on May 1, 2024, at 11:37 a.m., confirmed the deficiency.”