Initial Comments:
Name - A0101 Component - 01
Facility ID# 00178701
Component 01
Based on a Revisit to a Relicensure Survey completed on January 13, 2026, it was determined that Philadelphia Women's Center, Inc. was not in substantial 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 building, with a basement, that 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, document review, and interview, it was determined the facility failed to ensure testing of battery back up lighting was conducted and documented for one of eight levels within the facility.
Findings include:
Document review on January 13, 2026, between 9:00 a.m. and 10:00 a.m., revealed:
1. The facility could not produce documentation of the annual 90 minute testing of the battery back up lighting during the time of the survey.
Observation on January 13, 2026, at 10:35 a.m., revealed:
2. The battery backup lighting in the main electrical room failed to illuminate when tested.
Exit Interview with the Administrator on January 13, 2026, at 11:45 a.m., confirmed the missing testing documentation and the above physical deficiency.
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Based on observation and interview during an Onsite Revisit conducted on March 31, 2026, at 11:00 a.m., the following was determined:
Item 1. Not Completed. Annual 90 minute testing of the battery back up lighting was not available.
Item 2. Not Completed. Battery backup lighting in the main electrical room failed to illuminate when tested.
Exit Interview with the Administrator on March 31, 2026, at 11:45 a.m., confirmed the above items remained uncorrected.
Plan of Correction:1. As it relates to the deficiency, the Administrator communicated with the building owner to replace the batteries for the emergency lighting in the basement electrical room. The administrator communicated that the annual fire systems inspection, which includes 90 minute testing of the battery back up lighting, must be performed annually and in a timely manner. Furthermore, the Administrator requested a copy of said inspection report, as well as documentation of all corrective measures needed/taken as related to said report, including results of the required testing and how it was repaired.
2. To ensure compliance, the Administrator will review all reports upon completion of annual fire systems inspection. The Administrator will communicate in writing to the building owner to ensure that any systems failures are repaired in a timely fashion, so that the system remains in good working order.
3. The Administrator is responsible for ensuring that the building's contract for Fire Systems inspection includes the required testing of battery back up lighting. Furthermore, the Administrator will ensure the contract supports this testing being performed every 12 months.
4.This corrective action will be completed by June 1, 2026.
28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Installation
Name - A0101 Component - 01
Fire Alarm - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
20.3.4.2.1, 21.3.4.1, 9.6
Observations:
Based on observation and interview, it was determined the facility failed to properly install the fire alarm system, affecting the entire component.
1. Observation on January 13, 2026, between 9:00 a.m.,and 11:45 a.m., revealed during an inspection reset test of the fire alarm panel, there was no monitoring record of the remaining (1) supervisory alert on the local panel with the third party monitoring agency. In addition, third party monitoring company name and annual monitoring contract were not available for review at time of survey.
Exit Interview with the Administrator on January 13, 2026, at 11:45 a.m., confirmed notification was not supplied to security or staff of the facility about potential supervisory /trouble alarms on panel, and the monitoring company name with annual contract was not available to review.
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Based on observation and interview during an Onsite Revisit conducted on March 31, 2026, at 10:55 a.m., the following was determined:
Item 1. Not Completed. There was no monitoring record of the remaining (1) supervisory alert on the local panel with the third party monitoring agency. In addition, third party monitoring company name and annual monitoring contract were not available for review at time of survey.
Exit Interview with the Administrator on March 31, 2026, at 11:45 a.m., confirmed the above item remained uncorrected, including additional notification alerts noted on the panel during the Revisit.
Plan of Correction:1. As it relates to the deficiency, the Administrator communicated with the building owner to ensure that the local on-site panel properly synchronizes with the third-party monitoring agency so that all supervisory alerts are recorded and monitored in real time. Furthermore, the Administrator communicated to the building owner that the facility must be provided with a physical copy of the annual monitoring contract, including the company's contact information. The building owner communicated that they had the fire panel replaced/upgraded on April 8, 2026. The Administrator will contact the Division of Safety Inspection Plan Review Department for approval of the fire panel replacement/ upgrade.
2. To ensure compliance, the Administrator or their designee will monitor the local on-site panel monthly for a period of three months. If, during this monitoring period, there are any alerts on the local panel that are not received by the third party monitoring company in real time, the issue will be immediately reported in writing to the building's owner so that any necessary repairs can be made. Furthermore, if there are any communication failures between the local panel and third party monitoring company, the monitoring period will be extended for another three month period.
3. The Administrator is responsible for ensuring that transmission signals are verified with the monitoring company and that documentation is accurately maintained. This documentation will be provided to the Quality Assurance Performance Improvement (QAPI) Committee for review.
4. This corrective action will be completed by June 1, 2026.
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, documentation review and interview, it was determined the facility failed to ensure fire alarm systems were maintained and tested as required, affecting the entire component.
Findings include:
Document review on January 13, 2026, between 9:00 a.m. and 10:00 a.m., revealed:
1. No record of two year smoke detector sensitivity test.
2. No record of fire alarm annual maintenance and testing. Report dated 8/30/2024 supplied.
Observation and interview on January 13, 2026, at 11:00 a.m., revealed:
3. The fire alarm panel reported (1) supervisory on the panel.
a) Description: Fire Supervisory - Fire Tamper - Point of Origin - Basement Risers shutoff closed.
Exit Interview with the Administrator on January 13, 2026, at 11:45 a.m., confirmed the missing maintenance reports and that the panel had the deficiency listed without documentation of corrective actions.
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Based on observation and interview during an Onsite Revisit conducted on March 31, 2026, 10:30 a.m. through 12:00 p.m., revealed the following:
Item 2. Not Completed. Fire alarm systems report dated January 29, 2025 was provided. The following deficiencies were recorded without evidence of corrections:
a) Roof South Elevator Mechanical Room Shunt Trip Relay - Failed Operation;
b) Pull Station, on the first floor, Daycare exit to 8th Room 103;
c) Smoke Detector first Elevator Lobby, 8th street.
Item 3. Not Completed. The fire alarm panel reported (1) supervisory and (3) troubles on the panel at the time of revisit, as follows:
a) Fire Supervisory: Fire Pump Trouble;
b) Fire Trouble: Fire Pump Running;
c) Fire Trouble: second fl Waterflow;
d) Fire Trouble: second fl Riser Shut off closed.
Exit Interview with the Administrator on March 31, 2026, at 11:45 a.m., confirmed the deficiencies on the January 29, 2025 fire alarm report provided, and observation of supervisory and trouble conditions.
All other deficiencies listed under this tag were corrected.
Plan of Correction:1. As it relates to the deficiency, the Administrator communicated to the building's owner the necessity that the fire alarm maintenance and testing be performed annually and in a timely fashion. The building owner communicated that 2026 annual testing had been performed in February 2026; Administrator requested copy of said report, as well as documentation that any deficiencies noted during the inspection of the equipment have been repaired. The building owner also communicated that a new fire panel was installed on April 8, 2026. The Administrator will contact the Division of Safety Inspection Plan Review Department for approval of the fire panel replacement/ upgrade.
2. To ensure compliance, the Administrator will perform a quarterly document review of all inspected equipment relate to the Fire System and will communicate with the building's owner when inspection dates are approaching. Furthermore, the Administrator will monitor the fire panel on a monthly basis for a period of three months to ensure that there are no supervisory or trouble alerts on the new panel.
3. The Administrator is responsible for ensuring the document review and visual inspection of the equipment is performed quarterly. The results of this review, as well as the results of the physical panel monitoring will be reported to the Quality Assurance Performance Improvement (QAPI) Committee on a quarterly basis.
4. This corrective action will be completed by June 1, 2026.
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 properly maintain and test the automatic sprinkler systems with components, affecting the entire facility.
Findings include:
1. Document review on January 13, 2026, between 9:00 a.m. and 10:00 a.m., revealed the facility could not provide documentation of the following:
a. Internal Valve Inspection (5 yr);
b. Internal Pipe Insp (5 yr);
c. Obstruction Investigation
d. Electric Fire Pump Annual Inspection.
Exit Interview with the Administrator on January 13, 2026, at 11:45 a.m., confirmed the missing documentation.
2. Based on observation and interview, it was determined the facility failed to maintain sprinklers system components, affecting one of eight levels in the component.
Findings include:
Observation on January 13, 2026, between 9:00 a.m., and 11:30 a.m., revealed:
a) Basement Sprinkler Room: No battery backup emergency light located at the fire pump controller.
b) Basement Sprinkler Room: A dry sprinkler system valve assembly appeared to be installed but not maintained with wired / labeled fire alarm monitoring devices attached (44 & #45) at control valves.
Exit Interview with the Administrator on January 13, 2026, at 11:45 a.m., confirmed the missing emergency battery backup light and that the stationary dry sprinkler system valve assembly had wired fire alarm devices attached but appeared to not be in service.
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Based on observation and interview during an Onsite Revisit conducted on March 31, 2026, at 11:15 a.m., determined the following:
Item 1. Not Completed. The facility could not provide documentation of the following:
a. Internal Valve Inspection (5 yr);
b. Internal Pipe Insp (5 yr);
c. Obstruction Investigation;
d. Electric Fire Pump Annual Inspection.
Item 2. Not Completed. The facility failed to maintain sprinkler system components, affecting one of eight levels in the component.
a) Basement Sprinkler Room: No battery backup emergency light located at the fire pump controller;
b) Basement Sprinkler Room: A dry sprinkler system valve assembly appeared to be installed but not maintained with wired / labeled fire alarm monitoring devices attached (44 & #45) at control valves.
Exit Interview with the Administrator on March 31, 2026, at 11:45 a.m., confirmed the above items remained without corrective actions.
Plan of Correction:1. As it relates to the deficiency, the Administrator communicated to the building's owner the necessity that all listed inspections (internal valve, pipe, obstruction investigation, and electric fire pump inspection) be performed according to required schedule. The Administrator requested that all reports from said inspections be given to the facility, as well as documentation of repair if any of the inspections reveal failures/ non-functioning components. Furthermore, the Administrator communicated to the building's owner that all sprinkler system components must be well-maintained, including installation of battery backup emergency light at the pump controller and removal of any unnecessary, antiquated equipment.
2. To ensure compliance, the Administrator will perform a quarterly document review of all inspected equipment relate to the Fire System and will communicate with the building's owner when inspection dates are approaching.
3. The Administrator is responsible for ensuring that all necessary inspections be performed in a timely fashion and in accordance with NFPA 25. The results of these quarterly document reviews will be reported to the Quality Assurance Performance Improvement (QAPI) Committee quarterly.
4. All corrective actions will be completed by June 1, 2026.
28 Pa. Code § 569.2 STANDARD
HVAC
Name - A0101 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 inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting the entire facility.
Findings include:
1. Document review on January 13, 2026, between 9:00 a.m. and 10:00 a.m., revealed verification of four year damper inspection/testing was not available at the time of inspection.
Exit Interview with Administrator on January 13, 2026, at 11:45 a.m., confirmed the missing documentation.
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Based on observation and interview during an Onsite Revisit conducted on March 31, 2026, the following was determined:
Item 1. Not Completed. Verification of four year damper inspection/testing was not available .
Exit Interview with the Administrator on March 31, 2026, at 11:45 a.m., confirmed the above item remained without corrective actions.
Plan of Correction:1. As it relates to the deficiency, the Administrator communicated to the building's owner the necessity that the damper inspection/testing be performed in a timely manner in accordance with manufacturer's specifications. The Administrator requested that the report from said inspection be given to the facility, as well as documentation of repair if the inspection reveals failures/ non-functioning components.
2. To ensure compliance, the Administrator will perform a quarterly document review of all inspected components of HVAC system, including damper inspection/testing and will communicate with building's owner when inspection dates are approaching.
3. The Administrator is responsible for ensuring that the necessary inspection be performed in a timely fashion and in accordance with NFPA 25. The results of the quarterly document review will be reported to the Quality Assurance Performance Improvement (QAPI) Committee quarterly.
4. This corrective action will be completed by June 1, 2026.
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