QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - PED EXT CARE Component - 01

Facility ID #22164001
Component 01
Main Building

Based on a Relicensure Survey completed on September 7, 2023, at Aveanna Healthcare 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 one-story, Type II (000), unprotected noncombustible structure, which is not sprinklered.

Plan of Correction:

28 Pa. Code 569.2 STANDARD
Illumination of Means of Egress

Name - PED EXT CARE Component - 01
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
20.2.8, 21.2.8, 7.8


Based on observation and interview, it was determined the facility failed to maintain battery-powered emergency lighting, in one of two smoke compartments within the component.

Findings include:

1. Observation on September 7, 2023, at 10:30 AM, revealed the battery back-up emergency light, above the Therapy Room door in the corridor, failed, when tested, during the survey.

Interview with the Administrator on September 7, 2023, at 10:30 AM, confirmed the light did not function, when tested.

Plan of Correction:

S 569.2 Illumination of Means of Egress

1. The Facility Administrator will be responsible for ensuring that the battery in the affected back up emergency light unit is replaced by Sept 11, 2023.
2. On-going compliance will be monitored by performing a monthly exit and emergency lighting test, per the facility's safety plan. Findings are documented on the exit sign inspection checklist monthly. Any deficiencies will be addressed by the Facility Administrator.
3. Per the manufacturer, the lifespan of the MightyMax battery is 3-5 years. The Facility Administrator will institute a plan to change the batteries in the emergency lighting units every 4 years or as deemed necessary by the monthly testing.

Who: Facility Administrator
Plan of Correction Date: September 11, 2023