Initial Comments: Name - MAIN BUILDING 01 Component - 01
Facility ID 07541500 Component 01 First Floor
Based on a Relicensure Survey completed on January 9, 2023, it was determined that Grandview Surgery & Laser Center was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a four-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD Building Construction Type and Height Name - MAIN BUILDING 01 Component - 01 Building Construction Type and Height Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively.
Construction Type 1 I (442), I (332), II (222), Any number of stories II (111), III (211), IV (2HH), non-sprinklered or sprinklered V (111)
2 II (000), III (200), V (000) One story non-sprinklered Any number of stories sprinklered
Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met: 1. Such levels are under the control of the ambulatory health care occupancy. 2. Hazardous spaces are protected per section 8.7. Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively) 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. 20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain the rating of the floor/ceiling separation, in one of two smoke zones within the component.
Findings include:
1. Observation on January 9, 2023, at 1:50 PM, revealed a penetration of the ceiling deck, above the door to the Mechanical Room, in the Common Hall.
Interview at the time of the exit conference with the Administrator on January 9, 2023, at 2:30 PM, confirmed there was a penetration.
Plan of Correction:Building owners were notified on 1/9/23 of survey findings. All unsealed smoke barrier and/or ceiling deck penetrations noted will be addressed and fixed by 1/20/2023. Penetrations will be filled with a UL approved through stop penetration system by building maintenance personal. The rating of the ceiling assembly will be maintained after completion of any work. Any future work that needs to be completed and has compromised the smoke barriers will be addressed and fixed immediately. The MSDS/date sheet and product information for the UL approved stop penetration system used to seal the areas will be maintained by building owners and administrator. Inspections will be completed after any maintenance/contractor work is completed in any of the fire wall areas by building maintenance personal and any issues found will be fixed immediately and administrator will be notified.
28 Pa. Code § 569.2 STANDARD Hazardous Areas - Enclosure Name - MAIN BUILDING 01 Component - 01 Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7
Observations:
Based on observation and interview, it was determined the facility failed to maintain the rating of hazardous areas, in one of two smoke zones within the component.
Findings include:
1. Observation on January 9, 2023, at 2:30 PM, revealed a penetration, above the Mechanical Room door, from the Common Hall.
Interview at the time of the exit conference with the Administrator on January 9, 2023, at 2:30 PM, confirmed there was a penetration.
Plan of Correction:Building owners were notified on 1/9/23 of survey findings. All unsealed smoke barrier and/or ceiling deck penetrations noted will be addressed and fixed by 1/20/2023. Penetrations will be filled with a UL approved through stop penetration system by building maintenance personal. The rating of the ceiling assembly will be maintained after completion of any work. Any future work that needs to be completed and has compromised the smoke barriers will be addressed and fixed immediately. The MSDS/date sheet and product information for the UL approved stop penetration system used to seal the areas will be maintained by building owners and administrator. Inspections will be completed after any maintenance/contractor work is completed in any of the fire wall areas by building maintenance personal and any issues found will be fixed immediately and administrator will be notified.
|