QA Investigation Results

Pennsylvania Department of Health
AVEANNA HEALTHCARE
Building Inspection Results

AVEANNA HEALTHCARE
Building Inspection Results For:


There are  12 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
One Washington Square Building

Based on a Relicensure Survey completed on November 5, 2020, 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, with a basement, which is fully sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
General Requirements - Other

Name - PEDIARTIA HEALTHCARE WYNCOTE Component - 01
General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.

Observations:

Based on observation, interview and document review, it was determined the facility failed to provide a set of accurate portable life safety floor plans. The Division of Safety Inspection requires all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

Findings include:

1. Document review on November 5, 2020, at 8:30 a.m., revealed the facility could not provide a set of accurate portable life safety floor plans.

The Life Safety Code Floor Plans shall include the following:
a. Smoke Barrier Walls;
b. Fire Barrier Walls;
c. Horizontal Exits;
d. Hazardous Areas;
e. Required Exits should be clearly noted;
f. Shafts Walls.

Interview at the exit conference with the Administrator on November 5, 2020, at 10:20 a.m., confirmed the facility could not provide an accurate set of portable life safety floor plans.



Plan of Correction:

S0100 General Requirements, Other:

1. The facility has located an accurate portable life safety floor plan. It is available on site to be used during subsequent Life Safety Code Surveys.
The Life Safety Floor Plan on file includes the following details:
a. Smoke Barrier Walls
b. Fire Barrier Walls
c. Horizontal Exits
d. Hazardous Areas
e. Clearly Noted required exits
f. Shift Walls

2. The Area Director has uploaded the accurate life safety floor plan file to the company's share drive folder, as well as provided a copy to the building manager for his files, ensuring that a copy is always available on site.

3. Who is responsible for Plan of Correction: Area Clinical Director

4. Date of Completion: November 5, 2020



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 resistive rating of tenant separation walls, affecting the entire component.

Findings include:

1. Observation on November 5, 2020, at 9:40 a.m., revealed, inside the gym, above the suspended ceiling, there was an unsealed penetration in the tenant separation wall, around a data wire.

Interview at the exit conference with the Administrator on November 5, 2020, at 10:20 a.m., confirmed the unsealed penetration.







Plan of Correction:

System No. C-AJ-3230
F Rating - 3 Hr
T Rating - 1/2 Hr
1. Floor or Wall Assembly Min 5 in. thick normal weight (150 pcf) concrete. Wall may also be constructed of any UL Classified Concrete Blocks*. Max
diam of opening is 10-1/4 in.
See Concrete Blocks (CAZT) category in the Fire Resistance Directory for names of manufacturers.
2. Cables Aggregate cross-sectional area of cable in opening to be max 27 percent of the cross-sectional area of the opening. The annular space between
cables and periphery shall be min 0 in. (point contact) to max 3-1/2 in. Cables to be rigidly supported on both sides of floor or wall assembly. Any
combination of the following types and sizes of copper conductor cables may be used:
A. 1/C 750 kcmil (or smaller) copper conductor polyvinyl chloride (PVC) jacketed aluminum clad or steel clad TEK cable with cross-linked polyethylene
(XLPE) insulation.
B. 3/C 350 kcmil (or smaller) copper conductor PVC jacketed aluminum clad or steel clad TEK cable with XLPE insulation.
C. 4/C No. 14 AWG (or smaller) copper conductor PVC jacketed aluminum clad or steel clad TEK cable with XLPE insulation.
D. Max 25 pair No. 20 AWG (and smaller) copper conductor PVC jacketed cable with PVC insulation.
E. 1/C 400 kcmil (or smaller) aluminum or copper conductor cable with XLPE insulation.
F. 4/C No. 6 AWG (or smaller) copper conductor PVC jacketed cable with XLPE insulation
G. Through Penetration Product* Max 3/C No. 2 AWG (or smaller) aluminum or steel clad Armored Cable or aluminum or steel clad Metal Clad
Cable with copper conductors.
ALFEX CORP
3. Firestop System The firestop system shall consist of the following:
A. Packing Material Min 3-1/2 in thickness of min 4 pcf mineral wool batt insulation firmly packed into opening as a permanent form. Packing
material to be recessed from top surface of floor or from both surfaces of wall as required to accommodate the required thickness of fill material
(Item 3B).
B. Fill, Void or Cavity Material* Sealant Min 1/2 in. thickness of fill material applied within annulus, flush with top surface of floor or both
surfaces of wall. Sealant to be forced into interstices of cable group to max extent possible.
GRABBER CONSTRUCTION PRODUCTS INC GrabberGard IFC
*Bearing the UL Classification Marking


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 automatic sprinkler system components, affecting the entire component.

Findings include:

1. Observation on November 5, 2020, at 9:50 a.m., revealed, inside the oxygen storage room, there was a sprinkler missing an escutcheon.

Interview at the exit conference with the Administrator on November 5, 2020, at 10:20 a.m., confirmed there was a sprinkler missing an escutcheon.



Plan of Correction:

S 0353 Sprinkler System Maintenance

1.The facility is owned and maintained by employees of Carlino Associates, Penn Title Company. The missing escutcheon surrounding the sprinkler, located inside the oxygen storage room, has been replaced on November 13, 2020 by McGlocklin Construction, Inc.

2.Education has been provided to the necessary employees on November 9 and 11, 2020 regarding checking the components of the sprinkler system monthly thereby improving the accuracy and utilization of the logs already in place. Any discrepancies noted during inspection will be reported to the Administrative Director and service will be scheduled as soon as possible.

3.At the end of the month the Director will review the facility sprinkler head logs to ensure that the mechanisms are being regularly assessed and maintained properly.

4.Who is responsible for the Plan of Correction: Administrative Director

Date of Completion: November 13, 2020