Warren 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: 42642 Based on observation, document review, and interview, the facility failed to maintain general requirements not addressed by the provided K-tags, but are deficient, affecting one of two building components. 1. Document review on May 7, 2026, at 10:00 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 facilities manager on May 7, 2026, at 10:00 a.m., confirmed the Life Safety Code Floor Plan was unavailable at the time of the survey. 2. Observation on May 7, 2026 at 12:05 p.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from Life Safety Division for alterations to the roofing material and the replacement of skylights on all parts of the component. Interview with facilities manager on May 7, 2026 at 12:05 p.m., confirmed the facility was unable to provide documentation for the roof project at the time of the survey.”

“Building Rehabilitation CFR(s): NFPA 101 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) This Standard is not met as evidenced by: 42642 Based on observation, document review, and interview, the facility failed to maintain general requirements not addressed by the provided K-tags, but are deficient, affecting one of two building components. Observation on May 7, 2026, at 10:00 a.m., revealed the facility failed to obtain required approval from the Department of Health State Plan Review and a granted occupancy from the Life Safety Division for the change of use of the third floor chapel to a storage location. Interview with facilities manager on May 7, 2026, at 10:00 a.m., confirmed the facility was unable to provide documentation for the change of use at the time of the survey.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet multiple occupancy requirements for one of two building separations. Findings include: Observation on May 7, 2026, between 12:20 p.m. and 12:28 p.m., revealed the following multiple occupancies deficiencies: A. (12:20 p.m.) Fire door to the nurses station from the big day room lacked a closure arm and fire rated labels; B. (12:25 p.m.) Fire door F to the corridor in the big day room was propped open by a block of wood; C. (12:28 p.m.) Fire door 1157 was propped open by a chair. When tested, the door failed to positively latch in the frame. Interview with the facility fire marshall on May 7, 2026, at 12:28 p.m., confirmed the building separation deficiencies at the time of the survey.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet egress requirements for one of five common areas. Findings include: Observation on May 7, 2026, at 10:20 a.m., revealed the third floor chapel failed to have clear, visible exit signage at the time of the survey. One of two decommissioned and bricked-over exits had an exit sign mounted above the exit, which would cause confusion in the event of an emergency. The facility was unable to provide documentation for when the egress routes were redirected. Interview with facilities manager on May 7, 2026, at 10:20 a.m., confirmed the egress deficiency.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet requirements for doors with self-closing devices for one of over twenty doors. Findings include: Observation on May 7, 2026, at 12:40 p.m., revealed the room 1123 door to the exit had a self-closing device mounted to the door with the arm disconnected. Interview with the facility fire marshall on May 7, 2026, at 12:40 p.m., confirmed the door lacked a self-closing device arm.”

“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: 43722 Based on document review and interview, the facility failed to remain in compliance with sprinkler system regulations for one of two systems. Findings include: Document review on May 7, 2026, at 10:50 a.m., revealed the facility failed to provide documentation that the five-year internal valve and pipe inspection was completed at the time of the survey. Interview with the facility safety manager on May 7, 2026, at 10:50 a.m., confirmed the inspection documentation was not provided at the time of the survey.”

“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: 42642 Based on observation and interview, the facility failed to meet smoke barrier requirements in three of over five smoke compartments. Findings include: Observation on May 7, 2026, between 12:44 p.m. and 12:55 p.m., revealed the following smoke barrier deficiencies at the time of the survey: A. (12:44 p.m.) Mechanical room 1121 revealed a large cut out in the ceiling, allowing the passage of smoke; B. (12:50 p.m.) The big day room had areas damaged by water, allowing the passage of smoke; C. (12:55 p.m.) Room 133 had areas damaged by water, allowing the passage of smoke. Interview with the facility fire marshall on May 7, 2026, at 12:55 p.m., confirmed the areas permitted smoke passage.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 43722 Based on document review and interview, the facility failed to meet fire drill requirements for three of four testing quarters. Findings include: Document review on May 7, 2026, at 10:40 a.m., revealed the facility lacked complete documentation for the second, third, and fourth quarter fire drills for all three work shifts. Interview with the facility safety manager on May 7, 2026, at 10:40 a.m., confirmed the facility lacked documentation for the fire drills.”

“Soiled Linen and Trash Containers CFR(s): NFPA 101 Soiled Linen and Trash Containers Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet soiled linen and trash container requirements on three of four building levels. Observation on May 7, 2026, between 10:00 a.m. and 11:20 a.m., revealed the facility elevator room had soiled linen containers parked with laundry on each building level. Interview with facilities manager on May 7, 2026, at 10:20 a.m., confirmed the soiled linen containers on each floor.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 43722 Based on observation, document review, and interview, the facility failed to maintain required inspections for rated fire door assemblies, affecting the entire facility. Findings include: 1. Document review on May 7, 2026, at 11:20 a.m., revealed the facility lacked documentation that all the fire rated doors have been inspected within the previous twelve months. Interview with the facility safety manager on May 7, 2026, at 11:20 a.m., confirmed the lack of documentation for the yearly rated fire door inspection. 2. Observation on May 7, 2026, at 11:00 a.m., revealed the fire doors throughout the facility had panic hardware mounted in one hour and two-hour rated separations. Interview with the facilities manager and the facility safety manager on May 7, 2026, at 11:00 a.m., confirmed the lack of fire exit hardware.”

“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: 42642 Based on observation and interview, the facility failed to meet electrical equipment requirements in one of four smoke compartments. Observation on May 7, 2026, at 10:00 a.m., revealed the third floor chapel had an extension cord wired into the electric panel. Interview with facilities manager on May 7, 2026 at 10:00 a.m., confirmed the electric panel had an extension cord connection.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 39271 Based on review of facility documentation, credential file review (CF), as well as employee interviews (EMP), it was determined the facility failed to ensure that the medical staff examined the credentials of all eligible candidates for medical staff membership to make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and medical staff bylaws, rules, and regulations for one of 10 credential files [CF1]. Findings Include: Review, at approximately 10:34 AM on September 20, 2023, of “Clinical Privileging Criteria Warren State Hospital Medical Staff,” dated September 2023, revealed, “... Properly privileged physicians, CRNPs, dentists, podiatrists, and licensed independent practitioners under contract may or may not be members of the Medical Staff. The individual’s qualifications shall be evaluated against established criteria. This shall include a review of the individual’s professional competence, training, and ethical practices, and querying the National Practitioner Data Bank to comply with Title IV of the Health Care Quality Improvement Act of 1986. ... Appointments and reappointments shall be made by the Governing Body for Warren State Hospital on the recommendations of the Credentials Committee and the Medical Staff Executive Committee. All initial appointments shall be for a maximum period of two years of until the next reappointment process for the entire Medical Staff. ...” Review, at approximately 10:40 AM on September 20, 2023, of “Credentialing Procedure Warren State Hospital Medical Staff,” no date, revealed, “... Interested applicants receive the following packet of material to be completed and returned to the Medical Staff Secretary. ... Upon receipt of the above items, the Medical Staff Secretary requests the following information: ... Completed application is forwarded to Chairman of Department in which privileges are sought. Application with recommendation of Department Chairman, is forwarded to the Credentialing, Clinical Privileging, and By-Laws Committee. Credentialing, Clinical Privileging and By-Laws Committee schedules a meeting to review credentials of interested applicant. An interview with applicant may be requested at this time. Details will be handled by the Medical Staff Office. Application is reviewed, signed by committee chairperson, and presented with recommendations, to the Medical Staff Executive Committee. Upon approval by the Medical Staff Executive Committee, application is signed by the Chief Medical Officer and President of Medical Staff, then forwarded, with recommendations to the Governing Body for final approval. Applicant is notified of approval or disapproval, usually by telephone call. Applications shall be acted upon by the Credentialing, Clinical Privileging, and By-Laws Committee and the Medical Staff Executive Committee within a period of sixty (60) days. ...” 1. Review, at approximately 11:00 AM on September 19, 2023, of “Pennsylvania Department of Public Welfare,” dated June 30, 2021, revealed that CF1 was reappointed for a two-year period commencing on July 1, 2021. EMP3 confirmed the above findings at the time of observation. 2. Review, at approximately 10:51 AM on September 20, 2023, of “Warren State Hospital Psychiatry Services,” dated July 2023, revealed that CF1 was providing patient care for 18 days between July 5, 2023, and July 31, 2023. 3. Review, at approximately 10:55 AM on September 20, 2023, of “Warren State Hospital Psychiatry Services,” dated August 2023, revealed that CF1 was providing patient care for 21 days between August 1, 2023, and August 31, 2023. 4. Review, at approximately 10:57 AM on September 20, 2023, of “Warren State Hospital Psychiatry Services,” dated September 2023, revealed that CF1 was providing patient care for 12 days between September 1, 2023, and September 19, 2023. 5. EMP1 and EMP2 confirmed that CF1 has been providing care to patient’s after privileges expired on July 1, 2023.”