Pennsylvania Department of Health
UPMC ST MARGARET HARMAR OUTPATIENT CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 24 surveys for this facility. Please select a date to view the survey results.

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UPMC ST MARGARET HARMAR OUTPATIENT CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BLDG. - Component: 01 - Tag: 0000

Facility ID# 20601501
Component 01
Main Building

Based on a Relicensure Survey completed on June 20, 2024, it was determined that UPMC St. Margaret Harmar Outpatient Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a two-story, Type II (111), protected noncombustible building, without a basement, that is fully sprinklered.

Plan of Correction:

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

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: MAIN BLDG. - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting two of five smoke compartments.

Findings include:

1. Observation on June 20, 2024, revealed the following automatic sprinkler system deficiencies:
a) 8:45 a.m., there was a unsealed ceiling penetration in room 158;
b) 9:00 a.m., there was one ceiling penetration near the door at the loading dock;
c) 9:15 a.m., there were two unsealed ceiling penetrations in room 147.

Interview with the Facility Administrator and Maintenance Director on June 20, 2024, at 10:00 a.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 07/31/2024

Plan of correction: Ceiling penetration(s) will be sealed to resist the passage of smoke.
Completion Date: July 31, 2024
[Photographs will be provided as evidence of compliance.]

28 Pa. Code § 569.2 STANDARD HVAC:

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: MAIN BLDG. - Component: 01 - Tag: 0521
Based on documentation review and interview, it was determined the facility failed to complete the required four-year test and inspection of all smoke dampers throughout the facility.

Findings include:

1. Review of documentation on June 20, 2024, at 8:50 a.m., revealed there was no evidence that smoke dampers throughout the building had been inspected or tested in the last 48 months. Visual observation of the dampers revealed no inspection labels.

Interview with the Facility Administrator and Maintenance Director on June 20, 2024, at 8:50 a.m., confirmed the lack of documentation at the time of the survey.

Plan of Correction - To be completed: 07/31/2024

Plan of correction: Facility air damper inspection and testing has been scheduled and will be completed by 07/31/2024.
[A vendor, United Safety, has been contracted and is scheduled to perform the periodic testing and maintenance on July 10, 2024.
Purchase order # 0011287195 is provided as evidence that the plan of correction is in progress.]

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