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:


There are  9 surveys for this facility. Please select a date to view the survey results.

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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 September 20, 2022, 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
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 the smoke resistance of smoke barriers, affecting one of two levels in the facility.

Findings include:

1. Observation on September 20, 2022, between 10:45 a.m. and 11:05 a.m., revealed open conduit ends, following locations:

a. 10:45 a.m., Second floor, above the door to Electric room 203;
b. 11:05 a.m., Second Floor, above the door to Clean Assembly room 232.

Exit Interview with the Maintenance Supervisor and Regulatory Coordinator on September 20, 2022, at 11:30 a.m., confirmed the open conduit ends.





Plan of Correction:

For Item #372, two smoke barrier locations were identified with open conduits. These two penetrations were immediately sealed using a UL approved fire stop system on 9/20/2022. These penetrations were originally sealed but when the wiring was later modified, the seal became dislodged leaving the penetration open and unprotected.

To prevent a reoccurrence, maintenance staff will perform above ceiling annual inspections in accordance with the barrier wall management program. Staff will also be re-trained on the proper sealing of penetrations in fire resistant and smoke rated assemblies.


28 Pa. Code 569.2 STANDARD
Electrical Systems - Other

Name - (CHOP) BRANDYWINE VALLEY SPECIALTY Component - 10
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.

Observations:

Based on observation and interview, it was determined the facility failed to remove temporary wiring in accordance with NFPA 70 2011 Section 590.3 (D), affecting one of two levels within the facility.

Findings include:

1. Observation on September 20, 2022, at 11:06 a.m., revealed abandoned temporary wiring, above the ceiling, Second Floor, Sterile Equipment Storage, Room 234.

Exit Interview with the Maintenance Supervisor and Regulatory Coordinator on September 20, 2022, at 11:30 a.m., confirmed the abandoned temporary wiring.





Plan of Correction:

For Item #911, abandoned temporary wiring was identified in ceiling above the 2nd Floor Sterile- Equipment Storage Room 234. This abandoned temporary wiring was removed immediately on 9/20/22.

To prevent a reoccurrence, staff will be re-trained on identifying this issue in the field and the requirement to remove all abandoned wiring when no longer needed.