Clarks Summit State Hospital

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to provide the required building construction type, affecting the entire component Findings include: 1. Observation on May 23, 2024, at 10:00 a.m., revealed the building is a Type II (000) construction type, and lacks the complete automatic sprinkler system protection that is required for this type of construction. Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the component requires a complete automatic sprinkler system protection.”

“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: 19375 Based on observation and interview, it was determined the facility failed to maintain vertical openings in two locations, affecting two of two floors. Findings include: 1. Observation on May 23, 2024, between 11:12 a.m., and 11:23 a.m., revealed the following: a. 11:12 a.m., the 2014 pipe chase door, and door frame assembly labels were painted over. b. 11:23 a.m., the B-4 pipe chase door frame assembly lacked labeling. Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the vertical opening deficiencies.”

“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: 19375 Based on observation and interview, it was determined the facility failed to maintain three corridor openings, affecting one of one floor. Findings include: 1. Observation on May 23, 2024, between 10:00 a.m., and 10:32 a.m., revealed the following: a. 10:00 a.m., the Main Dining Room door 1080 lacked positive latching capabilities (roller latches). b. 10:06 a.m., the Main Dining Room door B-27 lacked positive latching capabilities (hardware removed). c. 10:32 a.m., the Resident Room door 15-18 door was not smoke-tight. Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the corridor opening defciencies.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in one location, affecting one of one floor. Findings include: 1. Observation on May 23, 2024, at 9:40 a.m., revealed the 1038 smoke barrier separation door failed to close when released from the magnetic hold-open device, due to contact with the floor. Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the smoke barrier door deficiency.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain the generator set in one instance, affecting three of three floors. Findings include: 1. Observation on May 22, 2024, at 10:05 a.m., revealed the generator set lacked an externally-located, emergency stop/shut-off, switch/button. Exit interview with the Facility C.O.O., the Facility Administrator, and the Facilities Manager on May 23, 2024, between 12:45 p.m., and 1:00 p.m., confirmed the generator set deficiency.”