Norristown State Hospital

“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: 39640 28 Pa. Code § 553.3(1) GOVERNING BODY RESPONSIBILITIES Governing body responsibilities include: (1) Conforming to applicable Federal, State and local law. This REGULATION has not been met. 35 P.S. § 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on observation, document review and interview, it was determined the following items did not conform to applicable Federal, State and local laws and regulations: Findings include: 1. Document review and observation on June 25, 2026, at 11:30 a.m., revealed the facility failed to secure plan approval by the Department of Health prior to constructing a wall to create a small room in the Men ’ s Toggery in the basement. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed the missing documentation. 28 Pa Code § 51.3. Notification (d)”

“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: 39640 Based on observation and interview, it was determined the facility failed to maintain hazardous areas, affecting one of three levels. Findings Include: 1. Observation on June 24, 2026, at 9:50 a.m., revealed, in ground floor linen chute discharge room, an unsealed penetration around data wires. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed the unsealed penetration.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 43767 Based on observation and interview, it was determined the facility failed to ensure required fire alarm components delaying alarm activation, affecting one of four levels within the facility. Findings include: 1. Observations on June 24, 2026, between 12:00 p.m., and 12:30 p.m., revealed that the following fire alarm installation deficiencies: a. Ground floor designated sleeping quarters for on-call doctors near room 074 failed to have a smoke detector installed in accordance with NFPA. b. Ground floor exit accessway door leading to the courtyard near door 079 failed to have a manual pull station installed within five feet of an exit per NFPA. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed the missing fire alarm components.”

“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: 42836 Based on document review and interview, it was determined the facility failed to maintain and test the sprinkler system, affecting the entire facility. Findings include: 1. Document review on June 24, 2026, at 8:15 am, revealed the facility could not produce documentation for the following tests: a. Annual control valve exercise; b. Annual main drain test. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed teh lack of documentation.”

“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: 39640 Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls, affecting one of three levels. Findings include: 1. Observation on June 24, 2026, at 10:45 a.m., revealed multiple unsealed penetration around data wires, ground floor above smoke doors by room 039. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed the penetrations.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 39640 Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of three levels. Findings include: 1. Observation on June 24, 2026, at 10:30 a.m., revealed a non-GFCI outlet located within 6 feet of a sink, 1st Floor 51B Med Room. Per NFPA 70 210.8(B)5, a GFCI outlet is required where receptacles are installed within 6ft of the outside edge of the sink. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed the unprotected outlet.”

“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: 50484 Based on observation and interview, it was determined the facility failed to protect electrical wiring in accordance with NFPA 99 2012 Edition, 6.3.2.1 Electrical Installation, affecting one of three levels within the facility. Findings include: 1. Observation made on June 25, 2026 at 10:50 a.m., revealed inside the basement maintenance room 04: a) Temporary lighting remained hanging from ceiling. b) Exposed wiring remained were mechanical devices were previously removed. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed the above electrical 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: 42836 Based on document review and interview, it was determined the facility failed to maintain and test the emergency generator, affecting the entire facility. Findings include: 1. Document review on June 24, 2026, at 8:15 am, revealed the facility could not produce documentation of the following tests: a. Weekly inspection of battery electrolyte leve or voltage; b. Monthly testing of battery sepcific gravity or conductance; c. Three year, four hour test. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed teh lack of documentation.”

“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: 39640 Based on observation and interview it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of three levels. Findings include: 1. Observations on June 24, 2026, revealed the improper use of electrical devices in the following locations: a. 10:00 a.m., ground floor room #041, portable AC unit plugged into a power strip. b. 10:45 a.m., 2nd floor doctor office #241, fridge and microwave into power strip. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed the unauthorized electrical device.”

“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: 39640 Based on observation and interview, it was determined that the facility failed to maintain oxygen storage requirements, affecting one of three levels. Findings include: 1. Observation on June 24, 2026, revealed the following oxygen storage deficiencies: a. 10:30 a.m., 1st floor 51B med room, 2-unsecured oxygen cylinders on a shelf. b. 10:50 a.m., 2nd floor room 285, 2- unsecured oxygen cylinders. Exit Interview with the Chief Operating Officer and Facilities Operations Manager on June 25, 2026, at 12:45 p.m., confirmed the oxygen storage deficiencies.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 01474 Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness program addressing the patient population, affecting the entire facility. Findings include: Documentation reviewed on January 4, 2024, revealed the Facility’s Emergency Preparedness plan did not address patient/client population, persons at risk, and the type of services the facility has the ability to provide in an emergency. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the EP plan did not specify the population served within the facility, in the event of an emergency.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 01474 Based on document review and interview, it was determined the facility failed to develop an Emergency Preparedness (EP) testing program to conduct exercises to test the emergency plan, affecting the entire facility. Findings include: Documentation reviewed on January 4, 2024, revealed the facility failed to conduct exercises to test the emergency plan twice per year. Documentation was provided for an individual facility-based exercise conducted in March 2023. A second full-scale community-based, individual, facility-based functional exercise, mock disaster drill, tabletop exercise or workshop led by a facilitator that included a group discussion was not available at the time of survey. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the facility failed to conduct required exercises for the Emergency Preparedness plan.”

“Facility ID# 40050100 Component 23 Building 51 Based on an unannounced Medicare Recertification Survey completed on January 4 - 5, 2024, it was determined that Norristown State Hospital - Building 51 Forensic Unit, was not in compliance with the following requirements of the Life Safety Code for an existing Hospital health care occupancy. Compliance with the National Fire Protection Association’s Life Safety Code is required by 42 CFR 482.41(b). This is a three-story, Type II (222), fire resistive construction, (ground, first, second floor), and a rooftop elevator machine room penthouse, which is non-sprinklered.”

“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: 01474 28 Pa. Code § 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met. 35 P.S. § 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility. Findings include: Observation and document review made on January 5, 2024, revealed the facility failed to secure plan approval by the Department of Health (Department) prior to initiating alterations to remove fire doors and seal the opening separating the tunnel at the A Wing, ground floor (Building 51). Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024 at 12:30 p.m., confirmed the facility failed to obtain Department-approved plans prior to initiating alterations and renovations. 28 Pa Code § 51.3. Notification (d)”

“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: 01474 Based on observation and interview, it was determined the facility failed to maintain means of egress free from obstructions, affecting 1 of four levels (Building 51). Findings Include: Observation made on January 5, 2024, revealed the facility was unable to locate keys to exit doors in a timely manner. There were several attempts to locate the appropriate key to Stair B door 1032, 1st floor. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the impediment to egress.”

“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: 01474 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair enclosures, affecting 1 of four levels (Building 1). Findings include: Observation on January 5, 2024, revealed partially sealed conduit penetrations in the corner of the stair wall, First Floor, A wing, short hall, above the stair enclosure door. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unsealed penetrations in the above named location.”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 01474 Based on observation and interview, it was determined the facility failed to maintain required illumination of the means of egress, affecting 1 of four levels (Building 1). Findings Include: Observation on January 5, 2024, revealed Stair 5 lacked two forms of illumination at the exit discharge, in the event one bulb becomes inoperable, Ground Floor. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the exit discharge required additional illumination.”

“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: 01474 Based on observation and interview, it was determined the facility failed to ensure exit directional signs were installed, affecting 1 of four levels (Building 10). Findings include: Observation on January 5, 2024, revealed the Center Hall lacked exit signage, E Wing, Second Floor. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the lack of exit signage.”

“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: 01474 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, affecting 1 four levels (Building 1). Findings include: Observation on January 5, 2024, revealed inside Mechanical Shaft 1088, next to the Laundry Room, there was a large opening in the ceiling and an unsealed duct penetration in the rear of the space. The duct penetration lacked access to verify installation of a fire damper, First Floor, E Wing. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unprotected vertical openings.”

“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: 01474 Based on document review and interview, it was determined the facility failed to maintain sprinkler system components in operable condition, affecting 3 of four levels (Building 1). Findings include: Documentation reviewed on January 4, 2024, revealed the internal sprinkler inspection & testing report dated February 1, 2022 for the linen chutes and Toggery room indicated they were unable to complete internal testing and were unable to shut the system down. Gauge valves are corroded and there was a clog in the system. The 4” OS&Y valve should be replaced. Verification of repair was not available at the time of inspection. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the deficienct sprinkler components.”

“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: 01474 Based on observation and interview, it was determined the facility failed to ensure fire extinguishers were installed properly, affecting 1 of four levels (Building 10). Findings include: Observation on January 5, 2024, revealed in the Second Floor, D-2 short hall, near Room 2011, the recessed fire extinguisher and locator light above the extinguisher had been removed. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, confirmed the fire extinguisher removal.”

“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: 01474 Based on observation and interview, it was determined the facility failed to maintain positive self-latching on corridor doors, affecting 2 of four floor levels (Building 1). Findings include: Observation on January 5, 2024, revealed there was a dogged-down feature on the latching device on the top half of the Med room corridor dutch door, located on each resident sleeping floor level, E Wing. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the impediment to door latching.”

“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: 01474 Based on observation and interview, it was determined the facility failed to ensure smoke barrier walls were free of unsealed penetrations, affecting 1 of five smoke zones (Building 10). Findings include: Observation on January 5, 2024, revealed on the First Floor above smoke barrier door 1012, near the Visitation Room 1011, there was a wire cut out penetration through the smoke barrier wall. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the smoke barrier wall penetration.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 01474 Based on observation and interview, it was determined the facility failed to ensure electrical wiring was protected, affecting 1 of four levels (Building 51). Findings include: Observation on January 5, 2024, revealed there was an open junction box with exposed inner wiring above the ceiling, near the smoke barrier partition, outside the Nurses’ Station, First Floor, A Wing; Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the unprotected electrical wiring.”

“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: 01474 Based on document review and interview, it was determined the facility failed to maintain HVAC (Heating, Ventilating, and Air Conditioning) equipment in operable condition, affecting 1 out of 205 dampers (Building 1). Findings Include: Documentation reviewed on January 4, 2024, revealed the damper inspection & testing report indicated damper 293 was not powered. Verification of repair was not available at the time of survey. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the damper was not functioning.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 01474 Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 1). Findings include: 1. Documentation reviewed on January 4, 2024, revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following: a. patient care rooms; b. visual inspection of physical integrity; c. correct polarity of the hot and neutral connections; d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz). Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the facility could not provide documentation the receptacles were tested.”

“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: 01474 Based on observation, document review and interview, it was determined the facility failed to maintain required inspections and components of the Essential Electrical System, affecting the entire facility (Building 1). Findings include: 1. Documentation reviewed performed on January 4, 2024, revealed the facility could not produce documentation of the following required testing and inspections for the emergency generator: a. Weekly visual inspections of the generator; b. Monthly battery conductance testing; c. Annual 90 minute Load Bank testing: d. No evidence of wet-stacking; e. three (3) year, four (4) hour load test; f. Annual fuel quality test. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing documentation. 2. Observation made on January 5, 2024, revealed the emergency generator transfer switch location lacked emergency back-up lighting. Exit Interview with the Chief Operating Officer, Facilities Operations Manager 4, Safety Manager and Fire Marshal on January 8, 2024, at 12:30 p.m., confirmed the missing emergency lighting.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 29817 Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to ensure registered nurses assigned the care of each patient to other nursing staff in accordance with the patient’s needs and qualification of the staff for 3 of 3 nursing units. (51A2, 51C2 and 10D1). Findings include: Review on December 6, 2023, of nursing policy “Assignment of Nursing Care” approved November 20, 2023 revealed “... Registered Nurses assigns the care of each patient to a Registered Nurse, Licensed Practical Nurse, Forensic Security Employee (FSEII) or Psychiatric Aide based on their currently clinical competency of that staff member to provide patient care needs ...” 1.Review on December 6, 2023, of facility document “Day Shift Daily Shift Assignment Sheet” not dated for nursing unit 51A2 revealed unit staff were assigned to patient care and special assignments. Interview on December 6, 2023 at approximately 11:00 AM with EMP1 confirmed FSEII complete the daily assignment sheet for patient care. 2.Review on December 6, 2023, of facility document “Daily Shift Assignment” dated December 6, 2023, for nursing unit 51C2 revealed unit staff were assigned to patient care and special assignments. Interview on December 6, 2023 at approximately 11:40 AM with EMP3 confirmed FSEII complete the daily assignment sheet for patient care. 3.Review on December 7, 2023, of facility document “Daily Shift Assignment” not dated for nursing unit 10D1 revealed unit staff were assigned to patient care and special assignments. Interview on December 7, 2023 at approximately 10:45 AM with EMP5 confirmed FSEII complete the daily assignment sheet for patient care.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 29817 Based on review of facility policy, medical records (MR) and interview with staff (EMP) it was determined the facility failed to ensure verbal orders were dated, timed and authenticated promptly by the ordering practioner in four of four medical records reviewed. (MR15, MR21, MR28 and MR30) Findings include: Review on December 6, 2023, of facility policy “Policy for Verbal Orders” not dated, revealed no provisions verbal orders are dated, timed and authenticated promptly by the ordering practioner. 1.Review on December 6, 2023, of MR15 physician documentation “Physician Orders” dated October 27, 2023, revealed a verbal order was obtained for patient care and the order was signed by a signature identified as the physician’s that issued the order. Further review revealed the verbal orders were not dated, timed and authenticated promptly by the ordering practioner. Review on December 6, 2023, of MR21 physician documentation “Physician Orders” dated October 27, 2023 and November 28, 2023, revealed verbal orders were obtained for patient care and the order was signed by a signature identified as the physician’s that issued the order. Further review revealed the verbal orders were not dated, timed and authenticated promptly by the ordering practioner. Interview with EMP2 on December 6, 2023, at approximately 12:00 PM confirmed the verbal orders were not dated, timed and authenticated promptly by the ordering practioner. 2.Review on December 7, 2023, of MR28 physician documentation “Physician Orders” dated November 18, 2023, revealed a verbal order was obtained for patient care and the order was signed by a signature identified as the physician’s that issued the order. Further review revealed the verbal orders were not dated, timed and authenticated promptly by the ordering practioner. Review on December 7, 2023, of MR30 physician documentation “Physician Orders” dated November 18, 2023, revealed a verbal order was obtained for patient care and the order was signed by a signature identified as the physician’s that issued the order. Further review revealed verbal orders were not dated, timed and authenticated promptly by the ordering practioner. Interview on December 7, 2023, with EMP5 at approximately 10:45AM confirmed verbal orders were not dated, timed and authenticated promptly by the ordering practioner.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 21962 Based on observation and interview with staff (EMP), it was determined the facility failed to ensure outdated medications were removed from service. Findings include: Tour conducted on December 6, 2023, at 11:00 AM of building 1, Unit C1 Medication Room had the following expired medications: Dozolamide HCL and Timolol Maleate Ophthalmic Solution with an expiration date of 10/2022 Ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5mg &3 mg /3 ml with expiration date March 2020. Tour conducted on December 6, 2023, at 12:20 PM of building 1, Unit C1 Medication Room had the following expired medications: A tube of triple antibiotic ointment that was open and had no cap on the tube and an expiration date of 8/2023. Artificial tears with an expiration date of 11/ 2022. Interview conducted on December 6, 2023, at 12:30 PM with EMP11 confirmed that the medications were expired and above findings.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 44109 Based on observations, review of facility policy and procedures and interviews with staff (EMP), it was determined the facility failed to adhere to established facility policies regarding the safe handling of patient food. Observation tour of dietary department on December 4, 2023, at 12:25 PM in the walk in refrigerator off of main food preparation area revealed, eight vacuum sealed bags of what appeared to be beef loins with one tray labeled only with the date “December 10, 2023” on the label. Review on December 5, 2023, of facility policy, “Food Handling Practices” , dated July 15, 2023, revealed, “...4 ...All items must be stored off the floor, and must be properly covered, labeled, and dated ...” Interview on December 4, 2023, at approximately 1:00PM with EMP9 confirmed the beef was only labeled with the date December 10, 2023. Interview on December 5, 2023, at 1:34 PM with EMP8 confirmed the labels on the beef did not follow facility policy regarding food handling practices. ______________________________________________________________________ Based on observations, review of facility policy and procedures and interviews with staff (EMP), it was determined the facility failed to adhere to established facility policies regarding the safe handling of patient food. Observation tour of dietary department on December 4, 2023, at 1:34 PM in the patient snack preparation area, inside the stand alone refrigerator revealed, single serve clear containers with lids marked with the contents of the cups. Further observation revealed: four (4) egg salad cups with no date label, seven (7) chicken salad cups with no date label, one (1) ham salad cup with no date label, and five (5) tuna cups with no date label. Review on December 5, 2023, of facility policy, “Food Handling Practices”, dated July 15, 2023, revealed, “...4 ...All items must be stored off the floor, and must be properly covered, labeled, and dated ...” Interview on December 4, 2023, at approximately 1:37 PM with EMP9 confirmed the single serve containers were not labeled with a date. Interview on December 5, 2023, at 1:41 PM with EMP8 confirmed the labels on the single serve cups did not follow facility policy regarding food handling practices.”

“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: 21962 Based on observation of patient care areas, and interview with staff (EMP), it was determined that the facility failed to ensure supplies were not outdated. Findings include: Tour conducted on December 6, 2023, at 11:00 AM of building 1, Unit A1 in the medication room had the following expired supplies: Non-Adhesive foam dressing 8 x 8 in with expiration date of 2020 -04 -01 Viral Transport for Viruses, Chlamydia, Mycoplasmas, and Urea plasmas with expiration date of 2021/04. Tour conducted on December 6, 2023, at 11:20 AM if building 1, Unit A1 at the Nursing Station had the following expired supplies: 14 F suction catheter with an expiration date of March 2020 Sterile alcohol prep pads with expiration date of 2021 /05 Nebulizer Kit with 7-inch (2.1 ml) oxygen level with expiration date of 2018/01. 2 Combine dressing with expiration date of 2008/03. G x 1 inch with expiration date of 2022-01-28. 5 packet of 3-0 silk suture with expiration date of 1/09. 1 Vanish Point syringe 3 ml 22G x 1 inch with expiration date of 2022-01-28. A suction container with “NSS” written on it. The container had no date or time. Suction Catheter with yellow packaging with a 2 inch dark stain on the package. The policy for expired for supplies was requested. The facility was unable to provide the requested document. The policy for beyond use date of supplies was requested. The facility was unable to provide the requested document. Interview conducted during the tour of the areas, with EMP11 confirmed that the supplies were expired and still available for patient use. Tour conducted on December 7, 2023, at 11:20 AM if building 1, Unit A 2 at the Supply Room had the following expired supplies: 6 containers of multipurpose wipes with an expiration date 3/10/22. 40 bottles of hand sanitizer with expiration dates of 5/23 or 7/22. One bottle of Perineal & Skin Cleanser with expiration date of Sept 2023. 5 Suture Removal Kits with an expiration dates of 2021 -11 Tour conducted on December 7, 2023, at 11:25 AM if building 1, Unit A 2 at the Medication Room had the following expired supplies: Four bottles of Hand sanitizer foam with an expiration date of 11/2023. Two bottle of Perineal & Skin Cleanser with an expiration date of Sept 2023. Bacti Swabs: Five with expiration dates of 2022 -04-27. 12 with expiration dates of 2022-10-19. 12 with expiration dates of 2022-04-27. Five with expiration dates of 2023-11-29. Glutose 15 (oral glucose gel) with expiration dates of 11-20-15 and 10-31-2023. Glucose controls with do not use after 2-28-23 written on sticker by staff. Tour conducted on December 7, 2023, at 11:25 AM if building 1, Unit C2 at the Supply Room had the following expired supplies: 50 bottles of Hand sanitizer with expiration date of 7/22. 20 bottles of Perineal & Skin Cleanser with expiration date of July 2020. The policy for expired for supplies was requested. The facility was unable to provide the requested document. The policy for beyond use date of supplies was requested. The facility was unable to provide the requested document. Interview conducted during the tour of the areas, with EMP12 confirmed that the supplies were expired and still available for patient use. Tour conducted on December 7, 2023, at 11:25 AM if building 1, Unit C2, environmental room revealed a hopper sink with gray couldy fluid in the sink. Staff was not able to flush the sink. Interview conducted during the tour of the areas, with EMP12 confirmed the sink would not flush. _____________ Based on observation and interview with staff (EMP) it was determined the facility failed to ensure outdated supplies were not available for use on patient care unit 51A2. A request was made on December 6, 2023, to EMP2 for policy regarding the use of outdated supplies. None provided. Review on December 6, 2023 of the manufacturer’s instruction for the use of glucose testing control solution revealed “...Check expiration dates on the control solution bottle ... discard control solution if either the Expiration date printed on the bottle or 3 months after opening ...” Observation on December 6, 2023, at approximately 10:30 AM of 51A2 medication area revealed the control solution containers for quality testing for the glucose meter were opened and not dated 3 months after opening. Further observation revealed the manufacturer’s printed expiration date on the bottle for level 1 control testing expired 12/31/20 and the manufacturer’s printed expiration date on the bottle for level 2 testing expired 5/31/21. Interview on December 6, 2023, at approximately 10:30 AM with EMP1 confirmed the control solution were not dated 3 months after the containers were opened and confirmed both containers of control solution were expired based on the manufacturers expiration date printed on the containers. ____________ Based on observations, review of facility policy and procedure and interviews with staff (EMP), it was determined the facility failed to ensure the physical facilities in a patient care area were maintained at an acceptable level of quality. Review on December 5, 2023, of facility policy and procedure, “Norristown State Hospital Housekeeping Department Policies and Procedures” , revised April 2022, revealed, “...Purpose and Function ...The purpose of the Housekeeping Services Department is to provide a clean, sanitary and attractive environment in a condition that complies with the standards of surveying and accrediting agencies and standards required by the Hospital and the Department of Human Services ...” 1.Observation tour of patient care unit C1 on December 6, 2023, at 12:17 PM in patient care room number 1026 revealed, inside the room’s exterior window, between the screen and shutters, there appeared to be two (2) bird nests made of brown straw or grass. Interview on December 6, 2023, at 12:17 PM with EMP2 confirmed there were two bird nests in the window of room 1026 in patient care unit C1. Further interview with EMP2 confirmed the bird nests should be removed. 2.Observation on December 6, 2023, at approximately 10:30 AM of patient care unit 51A2 revealed the floor in the entrance hallway had an accumulation of a black substance along the corners of the hallway floor and included approximately four inches of the wall. Continued observation revealed room 2434 had an accumulation of dust and unknown small pieces of debris scattered across the floor. Observation on December 6, 2023, at approximately 10:40 AM of the 51A2 nurses station revealed the flooring had an accumulation of a black substance along the corners of the floor, small peices of debris and dust. Further observation revealed multiple areas of an unknown dried substance on the wall behind the medication cart. Interview on December 6, 2023, at approximately 10:45 AM with EMP2 confirmed the observations of the hallway floors, room 2434 and nurses station. 3.Observation on December 6, 2023, at approximately 11:30 AM of patient care unit 51C2 revealed the floor in the entrance hallway had an accumulation of a black substance along the corners of the hallway floor and included approximately four inches of the wall. Further observation of the hallway adjacent to the nurses station revealed a thick coating of a gray substance along overhead pipes that were attached to the wall. Observation on December 6, 2023, at approximately 11:45 AM of the 51C2 nurses station revealed the flooring had an accumulation of a black substance along the corners of the floor, and small pieces of debris and dust. Further observation revealed multiple areas of an unknown dried substance on the wall behind the medication cart. Observation on December 6, 2023, at approximately 12:15 PM of the stairwell identified with door number 1020 leading from 51C2 to 51C1 revealed an accumulation of heavy dust and small pieces of debris. Interview on December 6, 2023, at approximately 12:30 PM with EMP2 confirmed the observations of the hallway floors, overhead pipes, nurses station and stairwell.”