Initial Comments:
Name - ASC ON 1ST FLOOR Component - 01
Facility ID #24841501
Component 01
Main Building
Based on a Relicensure Survey completed on March 21, 2024, it was determined that UPMC Community Surgery Center was not in compliance with the following requirements of the Life Safety Code for a new ambulatory health care occupancy.
This is a two-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered. ASF Unit is on the 1st floor.
Plan of Correction:
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - ASC ON 1ST FLOOR 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 and interview, it was determined the facility failed to provide documentation verifying a functional inspection of the fire alarm system had been performed within the previous twelve months, affecting the entire component.
Findings include:
1. Review of documentation on March 21, 2024, at 10:01 AM, revealed the facility failed to provide documentation verifying a functional inspection of the fire alarm system had been performed, since January 4, 2023.
Interview with the Nurse Manager on March 21, 2024, at 10:01 AM, confirmed the facility failed to provide documentation verifying a functional inspection of the fire alarm system had been performed within the previous twelve months.
Plan of Correction:The required functional inspection of the fire alarm system was completed on March 28, 2024, at 7 am. Documentation of this test is available upon request. To ensure fire alarm test compliance, the UPMC Central PA Corporate Real Estate team will utilize a computer-based work order system (CMS). This system will prompt the Property Manager and Senior Property Manager to request annual and semi-annual testing results from the landlord by March 28, 2025, and all years thereafter. To ensure sustained compliance, the Property Manager will conduct an annual audit to confirm that fire alarm testing was performed. Findings will be reported to the Senior Property Manager. Any results of non-compliance will be addressed with the staff and/or landlord.
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