QA Investigation Results

Pennsylvania Department of Health
CHILDREN'S HOSPITAL OF PHILADELPHIA BRANDYWINE VALLEY SPECIA
Building Inspection Results

CHILDREN'S HOSPITAL OF PHILADELPHIA BRANDYWINE VALLEY SPECIA
Building Inspection Results For:


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Initial Comments:
Name - (CHOP) BRANDYWINE VALLEY SPECIALTY Component - 10

Facility ID# 09661501
Component 10

Based on a Relicensure Survey completed on August 18, 2020, it was determined Children's Hospital of Philadelphia Brandywine Valley Specialty was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Health Care Occupancy.

This is a two-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Building Construction Type and Height

Name - (CHOP) BRANDYWINE VALLEY SPECIALTY Component - 10
Building Construction Type and Height
Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively.


Construction Type
1 I (442), I (332), II (222), Any number of stories
II (111), III (211), IV (2HH), non-sprinklered or sprinklered
V (111)

2 II (000), III (200), V (000) One story non-sprinklered
Any number of stories sprinklered

Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met:
1. Such levels are under the control of the ambulatory health care occupancy.
2. Hazardous spaces are protected per section 8.7.
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2

Observations:

Based on observation and interview, it was determined the facility failed to maintain fire resistive rated walls, affecting one of two smoke compartments.

Findings include:

1. Observation on August 18, 2020, at 10:15 a.m., revealed, in PACU alcove 249C, the rated access door to the mechanical shaft lacked a self-closing device.

Interview at the exit conference with the Director of Facilities Services and Maintenance Director on August 18, 2020, at 11:55 a.m., confirmed the fire rated door did not self-close.





Plan of Correction:

The one hour rated access door to the one hour rated mechanical shaft has been repaired on 9/15/2020. The access door is self-closing.

To prevent a reoccurrence, this location has been added to the existing fire door PM and will be inspected annually by maintenance staff. Staff have been trained on proper operation of the access door and the self-closing spring.




28 Pa. Code 569.2 STANDARD
Vertical Openings - Enclosure

Name - (CHOP) BRANDYWINE VALLEY SPECIALTY Component - 10
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 ensure vertical openings between floors were enclosed with the proper fire resistance rating, affecting one of two levels.

Findings include:

1. Observation on August 18, 2020, at 10:25 a.m., revealed, inside alcove 249C mechanical shaft, there was an unsealed penetration around a blue data wire.

Interview at the exit conference with the Director of Facilities Services and Maintenance Director on August 18, 2020, at 11:55 a.m., confirmed the unsealed penetration.





Plan of Correction:

Observation 0311
This penetration has been properly sealed using a UL approved fire stop system on 9/14/2020. The penetration was created by a data cable in the mechanical shaft.

To prevent a reoccurrence, maintenance staff will perform above ceiling annual inspections in accordance with the barrier wall management program.



28 Pa. Code 569.2 STANDARD
Subdivision of Building - Smoke Barrier

Name - (CHOP) BRANDYWINE VALLEY SPECIALTY Component - 10
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5

Observations:

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two floors.

Findings include:

1. Observation on August 18, 2020, at 10:30 a.m., revealed, above the smoke doors, by room 260, there was an unsealed penetration around an electrical box.

Interview at the exit conference with the Director of Facilities Services and Maintenance Director on August 18, 2020, at 11:55 a.m,. confirmed the unsealed penetration of the smoke barrier wall.





Plan of Correction:

Observation 0372
The open electrical junction box created an unprotected penetration in the one hour smoke barrier wall. The junction box was secured and closed up with a cover plate on 9/14/2020.

To prevent a reoccurrence, maintenance staff will perform above ceiling annual inspections in accordance with the barrier wall management program.



28 Pa. Code 569.2 STANDARD
Electrical Systems -Essential Electric System

Name - (CHOP) BRANDYWINE VALLEY SPECIALTY Component - 10
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:

Based on document review and interview, it was determined the facility failed to maintain required testing of the emergency generator, affecting the entire facility.

Findings include:

1. Document review on August 18, 2020, at 9:15 a.m., revealed the facility lacked documentation indicating performance of monthly testing and recording of electrolyte specific gravity or battery conductance testing in lieu of.

Interview at the exit conference with the Director of Facilities Services and Maintenance Director on August 18, 2020, at 11:55 a.m., confirmed the missing documentation.





Plan of Correction:

Observation 0918
The emergency generator is run and tested monthly. The batteries used on the generator are "maintenance free" but still need to tested.

To prevent a reoccurrence, maintenance staff will be trained on and will begin performing electrical conductance tests on the batteries as per NFPA 110, 2010, section 8.3.7.1 on the monthly PM beginning in October, 2020. The work description on the monthly PM will be updated to specifically include this requirement.