QA Investigation Results

Pennsylvania Department of Health
CHILDREN'S HOSPITAL OF PHILADELPHIA KING OF PRUSSIA SPECIALT
Building Inspection Results

CHILDREN'S HOSPITAL OF PHILADELPHIA KING OF PRUSSIA SPECIALT
Building Inspection Results For:


There are  13 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - KING OF PRUSSIA SPECIALTY CARE CENTER Component - 01

Facility ID# 24041501
Component 01

Based on a Relicensure Survey completed on February 19, 2021, it was determined that Children's Hospital Of Philadelphia King Of Prussia Specialty Care Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a four-story, Type II (000), unprotected non-combustible construction, with a mechanical penthouse, which is fully sprinklered.






Plan of Correction:




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

Name - KING OF PRUSSIA SPECIALTY CARE CENTER 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 in a secure condition, affecting one of four floors within this facility.

Finding include:

1. Observation on February 19, 2021, at 10:15 a.m., revealed inside the Ground Floor sprinkler riser room G002, there was a sprinkler riser flow alarm device with a loose cover.

Exit Interview with the Director of Maintenance on February 19, 2021, at 11:40 a.m., confirmed the flow alarm cover was loose.






Plan of Correction:

Observation Item 353
The sprinkler riser flow alarm device cover was secured during the time of the survey.

To prevent a reoccurrence, staff will be re-trained to inspect these covers during routine building tours and sprinkler PM's to ensure they are properly sealed. In addition, this item will be addressed with the sprinkler vendor who performs annual testing and inspecting of our system who need to ensure these are properly sealed as part of their work.



28 Pa. Code 569.2 STANDARD
Subdivision of Building - Smoke Barrier

Name - KING OF PRUSSIA SPECIALTY CARE CENTER Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5

Observations:

Based on observation and interview, it was determined the facility failed to maintain
the fire resistance of smoke barrier walls, affecting two of two smoke zones within the component.

Finding include:

1. Observation on February 19, 2021, between 10:50 a.m. and 11:02 a.m., revealed unsealed penetrations in the smoke barrier wall, above the suspended ceiling, in the following locations:

a. 10:50 a.m., inside Patient Room# 3072, around an approximately 6 inch in diameter chilled water pipe;
b. 11:02 a.m., inside Patient Room numbers 3043, 3044 and 3045, multiple conduit end openings were sealed with a non-rated white caulk.

Exit Interview with the Director of Maintenance on February 19, 2021, at 11:40 a.m., confirmed the unsealed penetrations.






Plan of Correction:

Observation Item 372

1a. This penetration will be properly sealed using a UL approved fire stop system by 3/12/2021. The penetration was created by an insulated 6" chilled water line. (System W-L-5014)

1b. The end caps of these penetrations in rooms 3043, 3044, and 3045 were sealed with a white caulk material. The white caulk will be removed and resealed using a UL approved fire stop system by 3/12/2021. (System W-L-3210)


To prevent a reoccurrence, maintenance staff will perform above ceiling annual inspections in accordance with the barrier wall management program.




28 Pa. Code 569.2 STANDARD
HVAC

Name - KING OF PRUSSIA SPECIALTY CARE CENTER 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 observation and interview, it was determined the facility failed to maintain protection of mechanical equipment, affecting one of four floors within this facility.

Finding include:

1. Observation on February 19, 2021, at 10:18 a.m., revealed near the Reception Desk in the corridor, above the ceiling, there was a VAV unit was missing its cover.

Exit Interview with the Director of Maintenance on February 19, 2021, at 11:40 a.m., confirmed the VAV unit was missing its cover.






Plan of Correction:

Observation Item 521
The VAV unit box cover was re-secured during the time of the survey inspection.

To prevent a reoccurrence, maintenance staff will perform above ceiling annual inspections in accordance with the barrier wall management program.



28 Pa. Code 569.2 STANDARD
Gas and Vacuum Piped Systems - Maintenance

Name - KING OF PRUSSIA SPECIALTY CARE CENTER Component - 01


Observations:

Based on document review and interview, it was determined the facility failed to maintain the medical gas and vacuum piped system, affecting one of one medical gas and vacuum piped systems within the component.

Findings include:

1. Document review on February 19, 2021, at 8:30 a.m., revealed the facility failed to repair deficiencies listed as "required repairs" in the September 8, 2020 medical gas and vacuum piped system annual inspection report, as follows:

a) four (4) cryogenic oxygen pigtails including CV's need to be replaced;
b) one (1) CO sensor requires replacement;
c) five (5) High Pressure pigtails including CV's need to be replaced.

Exit Interview with the Director of Maintenance on February 19, 2021, at 11:40 a.m., confirmed the deficiencies had not been repaired.






Plan of Correction:

Observation Item 907
Several items were noted as deficient on the annual inspection report performed on 9/8/2020 by our medical gas vendor. These items noted were not resolved by the time of this survey. The medical gas and vacuum system were functioning properly, but there were components identified as needing replacement which were past their manufacturer's recommended useful service life. The medical gas and vacuum system items noted are scheduled and will be completed by 3/12/2021.

To prevent a reoccurrence, the vendor will send a copy of the report directly to the Building Maintenance Supervisor and Director of Maintenance for review and correction of any deficiencies. If there are any future deficiencies found during the vendor's inspection, the Building Maintenance Supervisor and Director of Maintenance will be notified immediately by the vendor. For repairs that cannot be made at the time of the vendor's inspection, Facilities will schedule the repair to be made within one weeks time of notification.