Initial Comments:
Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01
Facility ID# 22944001
Component 01
One Washington Square Building
Based on a Relicensure Survey completed on September 25,2024, it was determined that 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 two-story, Type II (000), unprotected non-combustible building, with a basement, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01
Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44
Observations:
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the tenant separation wall.
Observation on September 25, 2024, at 9:40 a.m., revealed a penetration located in the ceiling above the exit door in the fire wall.
Exit interview with Location Director on September 25, 2024, at 10:56 a.m. confirmed the penetration in the fire wall.
Plan of Correction:S 0131 Multiple Occupancies
1.) The facility will ensure that it maintains the fire resistance rating of the tenant separation wall in accordance with the 6.1.14 sections of the ambulatory health care facilities regulations.
2.) The unsealed penetrations in the ceiling above the exit door in the fire wall, caused by the relocation of IT equipment, have been sealed by a technician at Specialty Electric utilizing fire resistant putty pads. This work was completed on October 11, 2024.
3.) The fire wall will be inspected any time that there is a relocation of IT equipment or other similar work at the suite. Any unsealed penetrations will be reported to the Administrative Director and service will be scheduled as soon as possible.
4.) Who is responsible for the Plan of Correction: Administrative Director
Date of Completion: October 11, 2024
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