Initial Comments:
Name - A0101 Component - 01
Facility ID# 00178701
Component 01
Based on a Relicensure Survey completed on March 27, 2023, 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 construction, with a basement, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Emergency Lighting
Name - A0101 Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
Observations:
Based on observation and interview, it was determined the facility failed to maintain emergency lighting in operable condition, affecting a main component of the facility electrical system.
Findings include:
1. Observation on March 27, 2023, at 10:54 a.m., revealed one of two emergency battery back-up lights failed to operate when tested, inside the basement main electrical room.
Exit Interview with the Facility Administrator on March 27, 2023, at 11:30 a.m., confirmed the emergency light failed to operate.
Plan of Correction:1. The deficiency will be corrected as it relates to the individual by asking the building owner to replace Emergency Light bulbs in the basement main electrical room.
2. To ensure the problem does not occur, the administrator will include the basement emergency lights in the monthly emergency lighting test, and keep documentation of monthly emergency lighting tests along with any findings in the fire safety binder and immediately acquire service/repair from the owner of the building on the affected light.
3. To ensure that these solutions are sustained, the administrator will immediately contact the owner f the building for service/repair of any findings noted during the monthly maintenance checks.
4. This corrective action will be completed by 05/01/2023
28 Pa. Code § 569.2 STANDARD
Vertical Openings - Enclosure
Name - A0101 Component - 01
Vertical Openings - Enclosure
2012 EXISTING
Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Unenclosed openings which do not serve as a required means of egress are permitted.
3. Exit access stairs may be unenclosed if they meet the following conditions:
Two stories or less
a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1).
b. Total travel distance to outside does not exceed 100 feet.
Three stories or less
a. Occupant load per story does not exceed 15 people.
b. Building is sprinkler protected throughout per 9.7.1.1(1).
c. Building contains an automatic smoke detection system per 9.6.
d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building.
e. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain vertical openings, including egress stairs, free of obstructions, affecting 1 of two stairtowers.
Findings include:
1. Observation on March 27, 2023, at 11:07 a.m., revealed the south stairtower housed a minimum of 4 bags of dry concrete mixture and a wood panel, at the basement level.
Exit Interview with the Facility Administrator on March 27, 2023, at 11:30 a.m., confirmed the egress stair housed storage.
Plan of Correction:1. The deficiency will be corrected as it relates to the individual by contacting the owner of the building and asking that the bags of concrete and wood panel be removed from the south stair tower at the basement level.
2. To ensure that the problem does not occur, the administrator will complete quarterly stair tower walkthroughs for the duration of the year 2023 and any finding will be immediately reported to the building owner/management for correction.
3. To ensure that these solutions are sustained, the administrator will document the quarterly stair tower walkthroughs on an updated internal checklist along with accompanying written communication to/from building owner/management.
4. This corrective action will be completed by 05/01/2023
28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Testing and Maintenance
Name - A0101 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, document review and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, affecting the entire facility.
Findings include:
1. Fire Alarm documentation reviewed on March 27, 2023, between 9:30 a.m. and 10:35 a.m., revealed failed devices, which included Control relay devices that were not connected to the shunt trip relay for the South Side and North Side elevators, previously cited on the inspection reports listed below. The reports also listed devices that were Untested. Fire alarm documentation identifying repairs and testing was not available at the time of this inspection.
a. February 2, 2023;
b. February 15, 2022;
c. February 14, 2021.
Exit Interview with the Facility Administrator on March 27, 2023, at 11:30 a.m., confirmed fire alarm system components required repair.
2. Observation made on March 27, 2023, at 11:00 a.m., revealed the main fire alarm panel located in the basement indicated the fire alarm system was in trouble mode.
Exit Interview with the Facility Administrator on March 27, 2023, at 11:30 a.m., confirmed the fire alarm system displayed a deficient condition.
Plan of Correction:1. This deficiency will be corrected as it pertains to the individual by:
a) connecting the control relay to the shunt trip relay in the north and south side elevators .
b) having building owner/management look into the reason that the fire alarm panel is in trouble mode and correct the problem.
c) building owner/management have been made aware of findings many times since deficiency was noted in 2021.
2. To ensure that the problem does not occur, the administrator will visualize the fire inspection report annually with a focus on potential deficiencies cited in the report. Noted deficiencies in need of repair/replacement will be documented in writing to the building owner/management until corrected.
3. To ensure that these solutions are sustained, the administrator will document the annual fire inspection review status in an email to the building owner/management and keep records of communication to/from building owner/management.
4. This corrective action will take place by 06/01/2023.
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - A0101 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 document review and interview, it was determined the facility failed to maintain required testing for the main sprinkler system fire pump, affecting the entire facility.
Findings include:
1. Documentation reviewed on March 27, 2023, between 9:30 a.m. and 10:35 a.m., revealed fire pump inspections for the main sprinkler system were not conducted on a consistent basis prior to April 2022, and after July 2022. Monthly 10 minutes runs are required for electric-driven motors.
Exit Interview with the Facility Administrator on March 27, 2023, at 11:30 a.m., confirmed fire pump testing was incomplete.
Plan of Correction:1. The deficiency will be corrected as it relates to the individual by requesting proper documentation of the monthly 10 minute exercise of the fire pump. Building owner/management has been made aware of this numerous times.
2. To ensure that the problem does not occur, the administrator will visualize the log in the basement on a monthly basis with a focus on completion of the monthly 10 minute exercise of the fire pump. Missing monthly tests will be documented internally and communicated to the building owner/management immediately until corrected.
3. To ensure that this solution is sustained, the administrator will document findings in an internal log along with accompanying written communication to/from building owner/management.
4. This corrective action will be completed by 06/01/2023
|