Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID# 10701500
Component 01
Based on a Relicensure Survey completed on February 5, 2021, it was determined Abington Memorial Hospital Endoscopy Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Health Care Occupancy.
This is a three-story, Type II (222), fire resistive structure, which is fully sprinklered.
Approved as a Class B Ambulatory Surgical Facility.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - CLASS B 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 and interview, it was determined the facility failed to ensure sprinklers were free of dirt and debris, affecting one of three floors within the component.
Findings include:
1. Observation on February 5, 2021, at 11:30 a.m., revealed a sprinkler, covered with debris, inside the mechanical closet, which is located within the reception office area.
Exit Interview with the Administator on February 5, 2021, at 12:20 p.m., confirmed the sprinkler with debris.
Plan of Correction:The Director Plant Operations is responsible for the corrective action and ongoing compliance.
All sprinkler heads in the facility were inspected and debris removed as needed on February 6, 2021. Inspection of sprinkler heads added to EOC rounding and work orders to be submitted for needed cleaning as need to insure ongoing compliance.
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier
Name - CLASS B 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 the fire resistive rating of smoke barrier walls, affecting one of three floors within the component.
Findings include:
1. Observation on February 5, 2021, at 11:45 a.m., revealed, above door #LVG F03, there was an unsealed penetration, around wires and a pipe, in the smoke barrier wall.
Exit Interview with the Administator on February 5, 2021, at 12:20 p.m., confirmed the unsealed penetrations.
Plan of Correction:The Director Plant Operations is responsible for the corrective action and ongoing compliance.
Identified penetrations above Door LVG-FO3 were sealed with approved hilti fire caulk February 6, 2021. Policy for above ceiling permits and work that require them to seal penetrations with approved hilti fire caulk will be reviewed with contractors by Director Plant Operations / designee by March 31, 2021.
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