Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID# 23631501
Component 01
Based on a Relicensure Survey completed on September 10, 2024, it was determined that Crozer Endoscopy Center (a Dept Of Crozer Chester Medical Center) was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a three-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Testing and Maintenance
Name - CLASS B ASF Component - 01
Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5
Observations:
Based on document review nd interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire component.
Findings include:
Document review on September 10, 2024, at 8:00 a.m., revealed the facility could not produce the following tests and inspections:
a. Semi-annual visual inspections within 6 months of 3/13/2024;
b. Smoke detector sensitivity within the past 2 years.
Exit interview with the Facilities Director on September 10, 2024, at 9:00 a.m., confirmed the lack of documentation.
Plan of Correction:The Director of Facilities Services met with the Brinton Lake Property Manager following the Life Safety survey and it was determined that the entity had coordinated the fire alarm system.
The smoke detector sensitivity testing was completed on 9/1/23. Documentation for the inspection has been obtained.
The Semi-annual visual inspections were completed on 9/1/2023. Documentation for the inspection has been obtained.
Moving forward the Director of Facilities Services will collaborate with the Brinton Lake Property Manager routinely to ensure all inspections are completed as required and inspection reports are provided to the Facilities leadership team.
The Director of Facilities Services currently has all the required documentation for the fire alarm system. Moving forward the proper manager will provide all required documentation to the Facilities leadership team as the fire inspections are completed.
Director of Facilities Services is ultimately responsible for this plan of correction.
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - CLASS B ASF 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 document review and interview, it was determined the facility failed to maintain and inspect the sprinkler system, affecting the entire component.
Findings include:
Document review on September 10, 2024, at 8:00 a.m., revealed the facility could not produce a sprinkler inspection for the third quarter of 2023.
Exit interview with the Facilities Director on September 10, 2024, at 9:00 a.m., confirmed the lack of documentation.
Plan of Correction:The Director of Facilities Services met with the Brinton Lake Property Manager following the Life Safety survey and it was determined that the entity had coordinated the sprinkler system inspection for the third quarter of 2023.
The sprinkler inspection for the third quarter of 2023 was completed on 7/10/23. Documentation for the inspection has been obtained.
Moving forward the Director of Facilities Services will collaborate with the Brinton Lake Property Manager routinely to ensure all sprinkler inspections are completed as required and inspections report are provided to the Facilities leadership team.
The Director of Facilities Services currently has all the required documentation for the sprinkler system. Moving forward the proper manager will provide all required documentation to the Facilities leadership team as the sprinkler inspections are completed.
The Director of Facilities Services is ultimately responsible for this plan of correction.
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