Initial Comments:
Name - MAIN BUILDING Component - 10
Facility ID# 298401
Component 10
Main Building
Based on a Relicensure Survey completed on Ju;y 18, 2023, it was determined that The Children's Home of Pittsburgh, was not in compliance with the following requirements of the Life Safety Code for a new ambulatory health care occupancy.
This is a three-story with basement and penthouse Type II (111), Protected noncombustible construction building that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Corridor - Doors
Name - MAIN BUILDING Component - 10
Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of nine smoke compartments.
Findings include:
1. Observation on July 18, 2023, at 9:00 a.m., revealed the following corridor door to Cindi's office had a unsealed penetration in the door.
Interview with the Facility Chief operating Officer and Maintenance Director on July 18, 2023, at 11:30 a.m., confirmed the corridor door deficiency.
Plan of Correction:This was an office door, not a cross-corridor door. We have installed a metal plate, as discussed with the surveyor, on both sides of the door handle. These metal plates cover all previous drill holes. We can provide a picture of this repair.
We are adding all corridor doors that are not firedoors, to our annual firedoor inspection to ensure they are evaluated on the same schedule and will recomplete the 2023 inspection.
NFPA 101 STANDARD
Fire Drills
Name - MAIN BUILDING Component - 10
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.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7
Observations:
Based on documentation review and interview, it was determined the facility failed to perform 3 of 12 required fire drills.
Findings include:
1. Review of documentation on July 18, 2023, at 8:30 a.m., revealed the facility lacked documentation for a third shift drill for the first quarter, and the second and third shift drills for the second quarter.
Interview with the Facility Chief Operating Officer and Maintenance Director on July 18, 2023, at 8:30 a.m., confirmed the facility lacked documentation for a drills between January and June in 2023.
Plan of Correction:We have created an annual schedule for Fire Drills to ensure we cover each of the shifts each quarter. This schedule has also been entered into our Preventive Maintenance system. These fire drills will be reported and reviewed at Patient Safety Committee meetings each month. The annual schedule is as follows:
Q1
January – 1st Shift, Child's Way
February – 3rd Shift, Blue Unit
March – 2nd Shift, Child's Way
Q2
April – 2nd Shift, Yellow Unit
May – 1st Shift, Child's Way
June – 3rd Shift, Green Unit
Q3
July – 2nd Shift, Child's Way
August – 3rd Shift, Family Living
September – 1st Shift, Child's Way
Q4
October – 1st Shift, Purple
November – 2nd Shift, Child's Way
December – 3rd Shift, Yellow Unit
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