Initial Comments:
Name - TENANT SPACE Component - 01
Facility ID# 50811501
Component 01
Based on a Relicensure Survey completed on February 6, 2024, it was determined that Bmmsa Heart And Vascular Center Of The Main Line was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.
This is a three-story, Type II (000), unprotected and non-combustible construction, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
HVAC
Name - TENANT SPACE Component - 01
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:
Based on document review and interview, it was determined the facility failed to maintain HVAC systems, affecting the entire facility.
Findings include:
Document review on February 6, 2024, at 8:15 a.m., revealed the facility could not provide documentation of a fire and smoke damper inspection within one year of installation.
Exit interview with the Administrative Director and the Facilities Manager on February 6, 2024, at 10:15 a.m., confirmed the lack of documentation.
Plan of Correction:The fire and smoke damper report could not be confirmed as the documentation was missing. We have rectified this as the testing was performed on 2/20/24
Fire dampers and smoke detectors operated properly.
The next test is not for 4 years. This has been shared with the Director of Nursing and the Maintenance Supervisor. It has been placed on the calendar and the company doing the testing was also made aware but will also be contacted 2 months prior to the due date set for January 13, 2027.
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