Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 11381500
Component 01
Based on a Relicensure Survey completed on October 23, 2023, it was determined Wills Surgery Center at The Philadelphia Stadium Campus 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 four quarters.
Findings include:
1. Document review on October 23, 2023, at 9:45 am, revealed the facility could not produce documentation showing quarterly sprinkler inspection had been performed- 4th quarter, 2022.
Exit Interview with the Administrator on October 23, 2023, at 11:10 am, confirmed the missing documentation.
Plan of Correction:1. On a quarterly basis the Administrator will utilize the inspection check list/log to make sure that the sprinkler inspection is performed on a timely manner and a report is provided by the inspecting company to verify inspection.
2. The Administrator will utilize the inspection check list/log to insure that inspections are performed timely.
3. Inspection check list/log will be presented to the Safety Committee in December 2023.
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