Initial Comments:
Name - 5910 KIRKWOOD STREET, PGH, PA. 15206 Component - 01
Facility ID# 00018701
Component 01
Main Building
Based on a Relicensure Survey completed on November 12, 2024, it was determined that Allegheny Reproductive Health Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Healthcare Occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 28 Pa Code 569.2.
This is a three-story, Type V (000), unprotected wood-frame building, with a basement, that is not sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Means of Egress - General
Name - 5910 KIRKWOOD STREET, PGH, PA. 15206 Component - 01
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1
Observations:
Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection in one instance, affecting the entire facility.
Findings include:
1. Review of documentation on November 12, 2024, at 8:30 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection, at the time of survey.
Interview with the Facility Maintenance Director on Novemeber 12, 2024, at 8:30 a.m. confirmed the annual fire door assembly inspection documentation was not available.
Plan of Correction:An "Annual Rated Fire Door Inspection" is done every year. The documentation for the 2024 calendar year was located in a different "safety & security" binder.
Documentation has since been added to all ARHC binders that contain information pertaining to safety & security and the facility in general. Inspections of rated fire doors include: condition of door, hardware, door frame, and automatic closure device. Staff member also checks to ensure proper closing of door.
Staff member will ensure that documentation is updated in all binders at the annual inspection going forward.
28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Testing and Maintenance
Name - 5910 KIRKWOOD STREET, PGH, PA. 15206 Component - 01
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:
Based on observation and interview, it was determined the facility failed to maintain smoke detection requirements in one instance, affecting the entire facility
Findings include:
1. Observation on November 12, 2024, at 9:00 a.m., revealed an unsealed ceiling penetration in the room containing the main fire panel.
Interview with the Facility Maintenance Director on November 12, 2024, at 9:00 a.m., confirmed the smoke detection deficiency.
Plan of Correction:The ceiling penetration will be sealed using either 3M fire barrier putty pads, 3M fire barrier putty, STI firestop putty, 3M fire block sealant/caulking or a combination of those items.
A notice will be posted at the site informing any work that creates penetrations in and around the main fire panel must be sealed using any of the fire block/barrier items listed above.
A staff member will perform a monthly visual inspection to ensure that any penetrations, old and new, are properly sealed.
|