Fairmount Behavioral cited for not meeting all federal, state and local laws and regulations around facility renovations

Fairmount Behavioral Health System was cited during an unannounced Medicare Validation Survey completed on July 29, 2013 by the Pennsylvania Department of Health (DOH) for violations of National Fire Protection Association’s Life Safety Code standards. DOH found that the facility “was not in compliance with the requirements of the Life Safety Code for an existing health care occupancy” in three areas of the facility: 1. a 54-bed addition for behavioral health, 2. adult inpatient unit, and 3. the adolescent building. DOH stated in the inspection report:
“The governing body, with technical assistance and advice from the hospital staff, shall do the following: Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.”
The inspection report stated that the facility in the Adolescent Building “did not conform to applicable Federal, State and local laws and regulations” because it was “undergoing renovations of the patient pods in order to install ligature resistant hardware and fixtures” but “had not submitted a narration of the renovations or plans for review by the Department of Health.” In an interview with the CEO, Director of Risk Management, and the Director of Facilities Management, it was “confirmed the facility had not submitted documentation of renovations for review.” In all three areas of the facility, DOH found doors that did not latch properly and needed repair. Specifically in the building addition, DOH found that the “corridor door to the kids dining room” along with the doors to “room 150” and “room 140” failed to latch and “needed excessive force to fully close and latch.” DOH also noticed that the “the boiler room [in the basement] had its latch receiver taped over, preventing the door from latching.” In the Adult Inpatient Unit, the report noted 6 out 8 patient room doors were completely missing the latching hardware, a Quiet Room door failed to positively latch, and another Quiet Room door latch was stuck in recessed position. DOH also found a patient door that was damaged, another door propped open by a chair, and a corridor door that had “four circular holes that penetrate the door near the handle where previous hardware had been removed.” Finally, in the Adolescent Building, DOH observed a door to a room that “did not have a latching mechanism and could not positively latch into the door frame.” Inspectors also found that the “corridor door of the isolation suite failed to stay latched when pressure was applied.” Inspectors noted observations in the basement level boiler room included “one sprinkler head was covered with plastic” and “one sprinkler head had spray fire proofing applied…[and] must be replaced.” DOH also found “solid shower curtains that would obstruct the water development pattern of the sprinkler heads” in two patient rooms and an entire wing of the building except for curtains in three patient rooms. In the Adult Inpatient Unit, inspectors also found “sprinkler heads with buildup of dirt and debris, which could delay the activation of the sprinkler” in the “N3 unit corridor by the nurse station and staff lounge” and the “N3 unit laundry room.” They also found a “drop down ladder attic access door was in the open position, exposing the mechanical space to the attic.” Also, the report noted that “the mechanical room is also being used to store large linen carts that were preventing the [attic] access door from closing. The linen carts were filled to the point that bags of linen within eighteen inches of the sprinkler heads.” DOH also “revealed the unauthorized or improper use of electrical devices” including a “microwave powered by a powerstrip powered by a[n] extension cord” and a “coffee maker powered by a[n] extension cord.” DOH also found the “improper use of extension cords, powerstrips, and outlet multipliers” in six areas throughout the adult inpatient unit. DOH found appliances including four refrigerators and one microwave oven plugged into powerstrips or extension cords. DOH also cited the facility for deficiencies related to accessible fire extinguishers, proper egress, and varying times of fire drills during all shifts. The CEO, Director of Risk Management, Quality Management, & Special Projects and the Director of Facilities Management all confirmed these findings in the exit interview on July 29, 2013. In the plan of correction, the facility agreed to complete monthly environmental rounds and address all deficiencies found in the inspection.