Initial Comments:
Name - A0101 Component - 01
Facility ID# 00248701
Component 01
Main Building
Based on a Relicensure Survey completed on September 14, 2023, it was determined that Planned Parenthood of Western Pennsylvania was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a five-story, Type IV (2HH), heavy timber building, with a basement, that is fully sprinklered.
Plan of Correction:
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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of five floors.
Findings include:
1. Observation on September 14, 2023, at 9:45 a.m., revealed there was a gap in the ceiling tile around the duct for the autoclave on the fifth floor. This would allow the passage of heat and smoke above the ceiling and may affect the operation of the automatic sprinkler system.
Interview with the Facility Administrator on September 14, 2023, at 10:30 a.m., confirmed the automatic sprinkler system deficiency.
Plan of Correction:The gap in the ceiling tile around the duct for the autoclave on the fifth floor, will be filled and sealed with fire-rated materials.
The work will be completed no later than October 14, 2023
Future prevention will include physical visual check of all future construction work completed to ensure proper barriers are in place to prevent heat and smoke above ceiling.
|