Initial Comments:
Name - BUILDING 02 Component - 02
Facility ID# 11894000
Component 02
East Wing 1st Floor
Based on a Relicensure Survey completed on March 13, 2024, it was determined that Child's Way, A Program of the Children's Home of Pittsburgh, was not in compliance with the following requirements of the Life Safety Code for an existing Pediatric Extended Care health care occupancy.
This is a three-story, Type II (111), protected noncombustible building, with a basement and penthouse, that is fully sprinklered. The Pediatric Extended Care facility is located on the first floor.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Fire Drills
Name - BUILDING 02 Component - 02
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7
Observations:
Based on documentation review and interview, it was determined the facility failed to perform two of 12 required fire drills, affecting the entire facility.
Findings include:
1. Review of documentation on March 13, 2024, at 8:45 a.m., revealed the facility lacked documentation for third shift fire drills in the second and third quarters.
Interview with the Facility Administrator and Maintenance Supervisor on March 13, 2024, at 10:00 a.m., confirmed the facility lacked documentation for third shift fire drills from April to September in 2023.
Plan of Correction:Fire Drills have been entered into an automatic PM program and the schedule checked and printed also to insure they are completed on all shifts as they are required. The Facilities Manager will review before the end of each month to insure they are correctly done according to the schedule for location of drill and shift schedule.
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