QA Investigation Results

Pennsylvania Department of Health
CHILD'S WAY, A PROGRAM OF THE CHILDREN'S HOME OF PITTSBURGH
Building Inspection Results

CHILD'S WAY, A PROGRAM OF THE CHILDREN'S HOME OF PITTSBURGH
Building Inspection Results For:


There are  19 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - BUILDING 02 Component - 02

Facility ID# 11894000
Component 02
East Wing 1st Floor

Based on a Relicensure Survey completed on February 13, 2019, it was determined that Child's Way, A Program of the Children's Home of Pittsburgh, was not in compliance with the following requirements of the Life Safety Code for an existing Pediatric Extended Care health care occupancy.

This is a three-story, Type II (111), protected noncombustible building, with a basement and penthouse, that is fully sprinklered. The Pediatric Extended Care facility is located on the first floor.





Plan of Correction:




28 Pa. Code 569.2 STANDARD
Means of Egress - General

Name - BUILDING 02 Component - 02
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 instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1

Observations:

Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection.

Findings include:

1. Review of documentation and interview with the Maintenance Supervisor on February 13, 2019, at 9:00 a.m., revealed the annual fire door assembly inspection had not been completed.

Interview with the Maintenance Supervisor on February 13, 2019, at 11:00 a.m., confirmed the annual fire door assembly inspection had not been completed.





Plan of Correction:

Fire Door Inspections: ALL fire doors throughout the facility will be thoroughly inspected per NFPA 80 Section 5.2.4.2 guidelines. An inspection sheet will be filled out showing that, at a minimum, all the 11 steps of this guideline were checked for each of the fire doors and all deficiencies that were found were corrected. The doors will be then be re-inspected within 30 days to insure all corrective action performed for repairs remains successful. The fire doors re-inspection will then be performed annually.


28 Pa. Code 569.2 STANDARD
Subdivision of Building - Smoke Barrier

Name - BUILDING 02 Component - 02
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.
21.3.7.5, 21.3.7.6, 8.5

Observations:

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier wall in two instances, on one of three floors.

Finding included:

1. Observation on February 13, 2019 at 11:00 a.m. revealed an unsealed penetration in the smoke barrier wall above the cross corridor doors leading to the Yellow unit, on the third floor.

Interview with the Facility Administrator and Maintenance Director, on February 13, 2019 at 1:30 p.m., confirmed the unsealed penetration.





Plan of Correction:

Smoke Barrier Penetrations: ALL smoke barrier wall penetrations will be thoroughly re-inspected and corrected using System No. W-L-8106 which was previously approved for this purpose by DOH. The smoke barriers are currently being inspected after any contractor works above the ceiling to make sure that they have not disrupted the barrier. If they do disrupt it, when they had to run wire or anything through it, they are then required to correct barrier using same system. The unsealed penetration found during most recent inspection was somehow missed during previous repairs and inspections but will be corrected immediately.