Pennsylvania Department of Health
PHILADELPHIA WOMEN'S CENTER, INC.
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PHILADELPHIA WOMEN'S CENTER, INC.
Inspection Results For:

There are  28 surveys for this facility. Please select a date to view the survey results.

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PHILADELPHIA WOMEN'S CENTER, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: A0101 - Component: 01 - Tag: 0000


Facility ID# 00178701
Component 01

Based on a Relicensure Survey completed on February 25, 2025, it was determined that Philadelphia Women's Center, Inc. was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 28 Pa Code 569.2.

This is an eight-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.



 Plan of Correction:


28 Pa. Code § 569.2 STANDARD Fire Alarm System - Testing and Maintenance:State only Deficiency.
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:
Name: A0101 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to ensure fire alarm systems, such as smoke detection devices, were maintained and tested as required, affecting the entire component.

Findings include:

Document review on February 25, 2025, between 9:00 a.m. and 11:30 a.m., revealed there were no records available indicating every two years the smoke detectors had a sensitivity test performed.

Exit Interview with the Administrator on February 25, 2025, at 11:30 a.m., confirmed the documentation was unavailable.





 Plan of Correction - To be completed: 06/30/2025

1. This deficiency will be corrected as it relates to the individual by requesting that building ownership complete and provide documentation of the smoke detectors sensitivity test.

2. To ensure that the problem does not occur, the administrator will bi-annually reach out to building ownership as a reminder that the sensitivity tests need to be completed on the smoke detectors.

3. To ensure that this solution is sustained, the administrator will maintain documentation of all communications with the building ownership as it pertains to the smoke detector sensitivity bi-annual test.

4. This corrective action will be completed by 06.31.2025
28 Pa. Code § 569.2 STANDARD Sprinkler System - Maintenance and Testing:State only Deficiency.
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:
Name: A0101 - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to properly maintain and test the automatic wet sprinkler system, affecting the entire facility.

Findings include:

1. Document review on February 25, 2025, between 9:00 a.m. and 11:30 a.m., revealed the facility could not provide documentation of the following:

a. Internal Valve Inspection (5 yr);
b. Internal Pipe Insp (5 yr);
c. Obstruction Investigation

Exit Interview with the Administrator on February 25, 2025, at 11:30 a.m., confirmed the missing documentation.


2. Based on observation and interview, it was determined the facility failed to maintain sprinklers, affecting one of eight levels in the component.
Findings include:
Observation on February 25, 2025, at 11:05 a.m., revealed a sprinkler escutcheon dislodged from the ceiling in "evaluation /PACA" hallway.
Exit Interview with the Administrator on February 25, 2025, at 11:30 a.m., confirmed the dislodged escutcheon.







 Plan of Correction - To be completed: 06/30/2025

1. This deficiency will be corrected as it relates to the individual by reaching out to the sprinkler contract company that completes PM's (Keystone) and by reaching out to building owner and requesting that building ownership complete and provide documentation of:

a) Internal Valve Inspection (5 yr);
b) Internal Pipe Insp (5 yr);
c) Obstruction Investigation


2. To ensure that the problem does not occur, the administrator will keep track of when these inspections are due and reach out to building ownership as a reminder that the Internal Valve Inspection, Internal Pipe Inspection, and Obstruction Investigation need to be completed. The administrator will reach out to our sprinkler contract company (Keystone)for replacement of any loose escutcheons during the next PM.

3. To ensure that this solution is sustained, the administrator will maintain documentation of all communications with the building ownership as it pertains to the Internal Valve Inspection, Internal Pipe Inspection, and Obstruction Investigation, which are due every five years. The administrator will ask Keystone to check escutcheons during all future PM's.

4. This corrective action will be completed by 06.30.2025
28 Pa. Code § 569.2 STANDARD HVAC:State only Deficiency.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Name: A0101 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting the entire facility.

Findings include:

Document review on February 25, 2025, between 9:00 a.m. and 11:30 a.m., revealed verification of four year damper inspection/testing was not available at the time of inspection.

Exit Interview with Administrator on February 25, 2025, at 11:30 a.m., confirmed the missing documentation.






 Plan of Correction - To be completed: 06/30/2025

1. This deficiency will be corrected as it relates to the individual by requesting that building ownership complete and provide documentation of the four year damper inspection/testing.

2. To ensure that the problem does not occur, the administrator will keep track of when this inspection is due and reach out to building ownership as a reminder that the four year damper inspection/testing need to be completed.

3. To ensure that this solution is sustained, the administrator will maintain documentation of all communications with the building ownership as it pertains to the damper inspection/testing, which are due every four years.

4. This corrective action will be completed by 06.30.2025
28 Pa. Code § 569.2 STANDARD Gas Equipment -Cylinder and Container Storage:State only Deficiency.
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: A0101 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to ensure medical gas cylinders were properly stored, affecting one of eight levels in the facility.

Findings include:

Observation on February 25, 2025, at 10:49 a.m., revealed behind the door in "patient meeting room 1" there were two free standing portable oxygen cylinders.

Exit Interview with the Administrator on February 25, 2025, at 11:30 a.m., confirmed the portable oxygen cylinders were not properly stored.






 Plan of Correction - To be completed: 06/30/2025

1. This deficiency will be corrected as it relates to the individual by ordering oxygen tank cylinder carts so that all tanks are being properly stored.

2. To ensure that the problem does not occur, the Director of Nursing will make the oxygen tanks a part of her monthly checks and document findings for a period of three months.

3. To ensure that this solution is sustained, the administrator will maintain documentation in the Monthly Spot Check Binder.

4. This corrective action will be completed by 06.30.2025

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