Initial Comments:
Name - PED EXTD CARE Component - 01
Facility ID# 20704001
Component 01
Based on a Relicensure Survey completed on January 3, 2024, it was determined that Frankie's World Foundation 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 one-story, Type II (000), unprotected non-combustible construction, with a mezzanine, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Means of Egress - General
Name - PED EXTD CARE Component - 01
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 document review and interview, it was determined the facility failed to properly document the required annual fire door inspection, affecting the entire facility.
Findings include:
Document review on January 3, 2024, at 11:30 a.m., revealed the facility could not produce documentation showing an annual fire door inspection was conducted.
Exit interview with the Administrator on January 3, 2024, at 12:30 p.m., confirmed the missing documentation.
Plan of Correction:Will be using the American Society for Healthcare Engineering Checklist for Fire Door Assemble Inspection (FDAI). For the annual fire door inspection. The documentation will be placed in the Fire Binder which is placed at the Reception area bookcase.
28 Pa. Code § 569.2 STANDARD
Emergency Lighting
Name - PED EXTD CARE Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
Observations:
Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was tested at required intervals, affecting the entire facility.
Findings include:
Document review on January 3, 2024, at 11:00 a.m., revealed documentation verifying an annual 90-minute test of the facility's battery back-up lighting was not available at time of survey.
Exit interview with the Administrator on January 3, 2024, at 12:30 p.m., confirmed the missing documentation.
Plan of Correction:A form was created and will be done every January that will show a 90 minute test of the back up lighting. This form will go into the orientation process of the maintenance worker position. Maintenance worker will come in one Saturday while children are out of building to conduct the test yearly in January. The documentation will be kept in the book labeled FIre Book which is kept at the reception area.
28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Testing and Maintenance
Name - PED EXTD CARE Component - 01
Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5
Observations:
Based on document review and interview, it was determined the facility failed to maintain Fire Alarm components, affecting one of two reports.
Findings include:
Document review on January 3, 2024, at 11:00 a.m., revealed the facility could not produce documentation showing a semi-annual fire alarm visual inspection had been performed.
Exit interview with the Administrator on January 3, 2024, at 12:30 p.m., confirmed the missing documentation.
Plan of Correction:Contacted Siemens and have on location documentation for quarterly inspection that was done on 1/2/24 at 1 pm. Email confirmation can be provided to show agreement with company that quarterlty inspections are scheduled.
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - PED EXTD CARE Component - 01
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
Observations:
Based on document review and interview, it was determined the facility failed to maintain the sprinkler system, affecting one of four inspections.
Findings include:
Document review on January 3, 2024, at 11:00 a.m., revealed the facility could not produce documentation showing a second quarter 2024 sprinkler inspection had been conducted as required.
Exit interview with the Administrator on January 3, 2024, at 12:30 p.m., confirmed the missing documentation.
Plan of Correction:
Contacted Siemens and have on location documentation for quarterly inspection that was done on 1/2/24 at 1 pm. Email confirmation can be provided to show agreement with company that quarterly inspections are scheduled. Director is responsible for following up on inspections.
28 Pa. Code § 569.2 STANDARD
Utilities - Gas and Electric
Name - PED EXTD CARE Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of two levels.
Findings include:
Observation on January 3, 2024, at 11:50 a.m., revealed, in the second floor storage closet, the electrical panel was missing a circuit breaker protective blank.
Exit interview with the Administrator on January 3, 2024, at 12:30 p.m., confirmed the missing blank.
Plan of Correction:Second floor storage closet panel fixed as of 1/10/24. Upstairs added to maintenance workers scheduled daily inspections.
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