QA Investigation Results

Pennsylvania Department of Health
PPSP SURGICAL LOCUST STREET HEALTH CENTER
Building Inspection Results

PPSP SURGICAL LOCUST STREET HEALTH CENTER
Building Inspection Results For:


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Initial Comments:
Name - AO1O1 Component - 01

Facility ID# 00238701
Component 01

Based on a Relicensure Survey completed on September 21, 2021, it was determined PPSP Surgical Locust Street Health Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Health Care Occupancy.

This is a three-story, Type II (000), unprotected non-combustible construction, with a lower level, which is fully sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Hazardous Areas - Enclosure

Name - AO1O1 Component - 01
Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7

Observations:

Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of hazardous area enclosures, affecting one of four levels within the facility.

Findings include:

1. Observation on September 21, 2021, at 11:00 a.m., revealed multiple unsealed penetrations in the fire rated boiler room wall, located in the basement, above the boiler room doors.

Exit interview with the Facilities Manager and Maintenance Representative, on September 21, 2021, at 12:00 p.m., confirmed the unsealed penetrations.






Plan of Correction:

PPSP will hire a fire proofing contractor to recommend and install a approved 3M Firestop System / UL Listed system to be used. Going forward all penetrations will need to be pre approved by Facilities Manager to ensure proper systems will be used.


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

Name - AO1O1 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 maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Observation on September 21, 2021, at 11:15 a.m., revealed the main sprinkler riser had a flow alarm cover missing a screw, located in the basement sprinkler riser area.

Exit interview with the Facilities Manager and Maintenance Representative, on September 21, 2021, at 12:00 p.m., confirmed the flow alarm cover was missing a screw.






Plan of Correction:

PPSP hired Kinetix contractor to install missing screw on flow alarm and to check all other tamper devices. Going forward Kinetix will monitor these devices during quarterly inspections. We also notified our alarm company to make sure all devices are properly secure and monitored yearly and semi annual.