QA Investigation Results

Pennsylvania Department of Health
AVEANNA HEALTHCARE
Building Inspection Results

AVEANNA HEALTHCARE
Building Inspection Results For:


There are  14 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01

Facility ID# 22944001
Component 01


Based on a Relicensure Survey completed on October 19, 2022, it was determined 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 construction, with a basement, which is fully sprinklered.



Plan of Correction:




28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - PEDIARTIA HEALTHCARE WYNCOTE 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 maintain smoke resistant ceiling assemblies, in sprinklered locations, affecting one location within the tenant space.

Findings Include:

1. Observation on October 19, 2022, at 11:51 a.m., revealed openings around conduit and pipe penetrations of the acoustic ceiling, Electric room.

Exit Interview with the Location Director on October 19, 2022, at 12:00 p.m., confirmed there were openings in the ceilings.





Plan of Correction:

S 0353 Sprinkler System Maintenance and Testing
1. The facility will maintain the smoke resistant ceiling assemblies, in sprinklered locations, in accordance with NFPA 25 Standards for the Inspection, Testing and Maintaining of Water-based Fire Protection Systems.
2. The openings noted around the conduit and pipe penetrations in the acoustic ceiling tiles located within the Electric Room were sealed on 10/28/2022, utilizing 3M Fire Caulk by Specialty Electric Co., Inc.
3. Semi-Annually, the ceiling acoustic tiles will be visually inspected. Any openings or visible concerns with the sealant will be immediately reported to the Building's Maintenance Manager and the Administrative Director and repair service will be scheduled as soon as possible.
4. Records of system maintenance will be maintained in the Administrative Director's office and made readily available upon request.



28 Pa. Code 569.2 STANDARD
HVAC

Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2

Observations:

Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating, and Air Conditioning (HVAC) equipment, affecting two of two dampers.

Findings Include:

1. Document review on October 19, 2022, between 9:00 a.m. and 11:00 a.m., revealed documentation was unavailable verifying four year exercising and testing of fusible link fire dampers.

Exit Interview with the Location Director on October 19, 2022, at 12:00 p.m., confirmed the (HVAC) system was not maintained.





Plan of Correction:

S 0521 HVAC
1. The facility will maintain the Heating, Ventilation, and Air Conditioning (HVAC) damper equipment in accordance with PA Code 9.2 and manufacturer's specifications.
2. Every four years, exercising and testing will be completed of the fusible link fire dampers, as established by the building owner's service agreement.
3. The Administrative Director has worked with the Building Property Manager to ensure that the proper damper inspection is completed. It is scheduled to be inspected on November 30, 2022, by Landis A.C. and Heating. Any necessary repairs or replacement parts to acquire full compliance with code will be completed by December 31, 2022, and the report will be available for review.
4. Records of system maintenance will be maintained in the Administrative Director's office and made readily available upon request.
Who: Administrative Director
Plan of Correction Date: December 31, 2022



28 Pa. Code 569.2 STANDARD
Fire Drills

Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01
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 observation, document review and interview, it was determined the facility failed to conduct fire drills within the requirements, affecting a minimum of four drills.

Findings Include:

1. Document review and observation on October 19, 2022, between 9:00 a.m. and 11:00 a.m., revealed fire drills are required to be conducted once per shift per quarter at unexpected times and under varying conditions. The following deficiencies were observed:

a. fire drills conducted for October thru December 2021, and January 2022, lacked times for each drill;
b. fire drills did not include the transmission of a fire alarm signal.

Exit Interview with the Location Director on October 19, 2022, at 12:00 p.m., confirmed fire drills were not conducted at various times with audible signaling.





Plan of Correction:


S 0712 Fire Drills
1. The facility will conduct fire drills per state regulations and company policy. A fire drill shall be conducted at least once quarterly at unexpected times under varying conditions.
2. Quarterly Fire Drills will include the transmission of a fire alarm signal and simulation of emergency fire conditions when conducted between the hours of 06:00 AM and 09:00 PM
3. Drills will be fully documented (to include date, time, and type) on the Fire/Disaster/Evacuation Drill Log and posted on the bulletin board in the therapy room hallway. Copies may be kept in a folder in the Administrative Director's office.
4. The Fire/Disaster/Evacuation Policy will be reviewed by the Administrative Director and Clinical Management team to ensure understanding of the policy and regulation.
5. Quarterly, the Administrative Director will confirm that the drills were conducted timely, documentation is complete, and outcomes were appropriate.
Who: Administrative Director



28 Pa. Code 569.2 STANDARD
Gas Equipment -Cylinder and Container Storage

Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to maintain storage of gas equipment, within sprinklered locations, affecting one location within the tenant space.

Findings Include:

1. Observation on October 19, 2022, at 11:25 a.m., revealed two E size oxygen cylinders were stored within five feet of combustibles, next to boxes, Storage room 122.

Exit Interview with the Location Director on October 19, 2022, at 12:00 p.m., confirmed the location of the oxygen tanks.





Plan of Correction:

S 0923 Gas Equipment Cylinder and Container Storage
1. The facility will maintain storage of gas equipment, within its sprinklered location, in accordance with 5.1.3.3.2 and 5.1.3.3.3 ensuring that oxidizing gases are separated from combustibles by 20 feet.
2. The E size oxygen cylinder storage was relocated on Friday 10/21/2022 to an area that meets the standards noted above.
Who: Administrative Director