QA Investigation Results

Pennsylvania Department of Health
AVEANNA HEALTHCARE
Building Inspection Results

AVEANNA HEALTHCARE
Building Inspection Results For:


There are  10 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01

Facility ID# 22944001
Component 01
One Washington Square Building

Based on a Relicensure Survey completed on September 7, 2018, it was determined Pediatria Healthcare For Kids 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 two story, Type II (000), unprotected non-combustible construction, with a basement, which is fully sprinklered.






Plan of Correction:




28 Pa. Code 569.2 STANDARD
Multiple Occupancies

Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01
Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44

Observations:

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of common walls, affecting one of two levels.

Findings include:

1. Observation made on September 7, 2018, at 9:20 am, revealed above the rear entrance door on the lobby side, there was an unsealed penetration of the common wall around conduit and data wires.

Interview at the exit conference with the Administrator on September 7, 2018, at 10:00 am, confirmed the unsealed penetration.










Plan of Correction:

An outside company, Jersey Firestop was secured on October 4, to assess all Firewall and conduit penetrations. Upon completion of the assessment, plans and drawings will be available to identify all penetrations and the type of firestop/fire barrier implemented to meet fire resistance ratings in accordance with NFPA 221 guidelines.



5. Who is responsible for Plan of Correction: Administrative Director
Date of Completion: November 9, 2018




28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - PEDIARTIA HEALTHCARE WYNCOTE 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 observation and interview, it was determined the facility failed to ensure sprinkler components were maintained within a smoke resistant ceiling assembly, free of debris, affecting one of two levels.

Findings include:

1. Observation on September 7, 2018, at 9:20 am, revealed inside the electrical room, there was an unsealed penetration of the ceiling assembly around cables.

Interview at the exit conference with the Administrator on September 7, 2018, at 10:00 am, confirmed the unsealed penetration.


2. Observation on September 7, 2018, at 9:40 am, revealed inside the kitchen, there was a sprinkler with a build-up of dust on the bulb.

Interview at the exit conference with the Administrator on September 7, 2018, at 10:00 am, confirmed the build-up of dust on the sprinkler.










Plan of Correction:

1. The facility is under contract to be cleaned daily, with additional attention scheduled monthly to focus on areas such as the sprinkler mechanisms, per the contract with GCJ Cleaning The sprinkler heads throughout the center have been cleaned of any dust residue on September 15 , 2018.
3. Checking the cleanliness of all sprinkler mechanisms will be added to the facilities monthly cleaning plan and documented on the facility cleaning Log. Any discrepancies noted will be reported to the Administrative Director and service will be scheduled as soon as possible.
4. At the end of the month the Director will review the facility cleaning Log to ensure that the cleanliness of the sprinkler mechanisms are being regularly assessed and are cleaned properly.

1. The ceiling tiles have been sealed surrounding the cables for the circuit breaker boxes located inside the electrical room on October, 2018 by JBC Cleaning LLC in order to maintain water-based fire protection within a smoke resistant ceiling assembly.
2. The following pictured items were used to seal the penetrations:
a. 3M Fire Barried Sealant CP 25WB
b. 3M Fire Block foam FB-foam
c. Owens Corning Thermafiber Fire and Sound Guard

5. Who is responsible for Plan of Correction: Administrative Director
Date of Completion: October 12, 2018



28 Pa. Code 569.2 STANDARD
Fire Drills

Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at 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. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7

Observations:

Based on document review and interview, it was determined the facility failed to conduct quarterly fire drills, affecting two of four required quarters.

Findings include:

1. Document review on September 7, 2018, between 8:15 am and 9:15 am, revealed the facility failed to provide written documentation of quarterly fire drills for the first quarter 2018, and the fourth quarter of 2017.

Interview at the exit conference with the Administrator on September 7, 2018, at 10:00 am, confirmed the fire drill documentation was unavailable at time of survey.









Plan of Correction:

E0022 REQUIREMENT DISASTER PLAN:
SECTION 15. Regulations. Requirements. (b)(13)

Fire Drills will be conducted according to PPECC PA Act 54 of 1999 and Pediatria HealthCare Policy for monthly disaster/fire drills. The company policy states that fire drill shall be conducted at least once every two months. A disaster drill shall be practiced every month, and a full evacuation shall occur at least once every six months at various times of the day and days of the week. All employees should be included at least quarterly. Reports of such drills will be documented on the Fire/Disaster/Evacuation Monthly Drill Log and reported quarterly to the PI committee.

Fire Drills shall be conducted according to policy and the PPECC PA Act 54 of 1999. The administrative director will plan and initiate the fire drill considering the employees that need to participate and the type of drill that is necessary. The administrative assistant will document the details on the Fire/Disaster Monthly Drill Log. The clinical coordinators will train all new employees on fire/disaster/evacuation policy procedure during new employee orientation.

Fire Drills will be conducted in June, August, October, December, February, and April. The administrative director will schedule the monthly drills on the company Google calendar specifying fire drill months. The calendar events will have a reminder feature to prompt the administrative director of the upcoming due date. The Fire/Disaster Monthly Drill Log will be submitted to the Area Clinical Director Regional Vice President for verification of compliance each month after the drill is completed for a total of 12 months.

Who: Administrative Director

Plan of Correction Date: 11/02/2018