QA Investigation Results

Pennsylvania Department of Health
CHOP BUCKS SPECIALTY CARE AND AMBULATORY SURGERY CENTER
Building Inspection Results

CHOP BUCKS SPECIALTY CARE AND AMBULATORY SURGERY CENTER
Building Inspection Results For:


There are  25 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - CLASS C ASF Component - 01

Facility ID# 10581500
Component 01
Main Building

Based on a Relicensure Survey completed on April 14, 2021, it was determined CHOP Specialty Care And Ambulatory Surgery Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a one-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered.





Plan of Correction:




28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - CLASS C ASF 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, document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of three smoke compartments.

Findings include:

1. Observation on April 14, 2021, at 11:10 a.m., revealed a missing sprinkler escutcheon in the Main Reception Area above the desk, near the restroom.

Exit Interview with the Director of Maintenance Technical Services and Maintenance Supervisor on April 14, 2021, at 11:45 a.m., confirmed the missing escutcheon.






Plan of Correction:

Observation # 0353:
The sprinkler escutcheon plate has been re-installed in the ceiling above the front desk check out counter on 4/21/2021. (Work Request # 1107303)
It is not known how or why this escutcheon plate was not present during the time of the survey. Staff inspected the other sprinklers in the building and did not see any other plates missing.
To prevent a re-occurrence, staff will be re-trained on sprinkler inspections while performing rounds in the building.



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

Name - CLASS C ASF Component - 01
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 two of three smoke compartments.

Findings include:

1. Observation on April 14, 2021, at 10:00 a.m., revealed an unsealed penetration around a copper pipe, above the door, in the Kitchenette.

Exit Interview with the Director of Maintenance Technical Services and Maintenance Supervisor on April 14, 2021, at 11:45 a.m., confirmed the unsealed penetration.






Plan of Correction:

Observation # 0372:
Staff re-sealed the above ceiling copper pipe penetration in the existing smoke barrier with an approved UL fire stop system on 4/21/2021. (Work Request # 1107301)
To prevent a reoccurrence, maintenance staff will perform above ceiling annual inspections in accordance with the barrier wall management program.