Initial Comments:
Name - UPMC PRESBYTERIAN Component - 01
Facility ID# YU6T0101
Component 01
Presbyterian Hospital Eleventh Floor D-Wing
Based on a Recertification Survey completed on November 4-5, 2024, it was determined that UPMC Presbyterian was not in compliance with the requirements of the Life Safety Code for an existing ESRD health care facility. Compliance with the National Fire Protection Association's Life Safety Code, is required by 42 CFR 494.60(e)(1).
This is a thirteen-story, Type II (222), fire resistive building, without a basement, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Multiple Occupancies
Name - UPMC PRESBYTERIAN 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 two-hour fire resistance rating in the D Wing, affecting one of 13 smoke compartments.
Findings include:
1. Observation on Novemeber 4, 2024, at 9:00 a.m., revealed the door next to A 1305, on the 13th floor, was propped open.
Interview with Facility Staff on November 5, 2024, at 11:00 a.m., confirmed the deficiency for doors in a two-hour fire rated occupancy separation wall.
Plan of Correction:Door prop was removed, and door was verified to close and latch properly. Staff were educated not to prop door. Compliance with this corrective action will be reported to the hospital safety committee and tracked as part of the Quality Assurance Program. Ongoing compliance will be monitored during hazard surveillance rounds.
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - UPMC PRESBYTERIAN Component - 01
Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7
Observations:
Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of thirteen smoke compartments.
Findings include:
1. Observation on November 5, 2024, at 8:50 a.m., revealed one large unsealed pipe penetration in the fire wall separation, above the D-Wing smoke doors, next to Room D133.
Interview with Facility Staff on November 5, 2024, at 11:00 a.m., confirmed the unsealed pipe penetration.
Plan of Correction:Penetration was sealed using approved fire stop material. Compliance with this corrective action will be reported to the hospital safety committee and tracked as part of the Quality Assurance Program. Ongoing compliance will be monitored during hazard surveillance rounds.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - UPMC PRESBYTERIAN 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 the automatic sprinkler system in five instances, in four of 13 smoke compartments.
Findings include:
1. Observation on November 4, 2024, revealed the following automatic sprinkler system deficiencies:
a) 8:50 a.m., wires were supported by the sprinkler lines next to the A Stem Door, on the twelfth floor;
b) 9:35 a.m., duct work was supported by the sprinkler line next to room D 961, on the ninth floor.
Interview with Facility Staff on November 5, 2024, at 11:00 a.m., confirmed the automatic sprinkler system deficiencies.
2. Observation on November 5, 2024, revealed the following automatic sprinkler system deficiencies:
a) 8:30 a.m., there were three unsealed ceiling penetrations in room D226A on the second floor;
b) 8:20 a.m., there was a sprinkler line mounted to the ceiling with ceiling tile hangar wire, above the smoke doors near Room D226A.
Interview with Facility Staff on November 5, 2024, at 11:00 a.m., confirmed the automatic sprinkler system deficiencies.
Plan of Correction:Observation 1A: Wires were removed from the sprinkler line and properly supported. Compliance with this corrective action will be reported to the hospital safety committee and tracked as part of the Quality Assurance Program. Ongoing compliance will be monitored during hazard surveillance rounds.
Observation 1B: Duct work was properly supported and removed from the sprinkler line. Compliance with this corrective action will be reported to the hospital safety committee and tracked as part of the Quality Assurance Program. Ongoing compliance will be monitored during hazard surveillance rounds.
Observation 2a: The ceiling penetrations were sealed using approved fire stop material. Compliance with this corrective action will be reported to the hospital safety committee and tracked as part of the Quality Assurance Program. Ongoing compliance will be monitored during hazard surveillance rounds.
Observation 2B: Sprinkler line was properly supported. Penetration was sealed using approved fire stop material. Compliance with this corrective action will be reported to the hospital safety committee and tracked as part of the Quality Assurance Program. Ongoing compliance will be monitored during hazard surveillance rounds.
NFPA 101 STANDARD
Subdivision of Building Spaces - Smoke Barrie
Name - UPMC PRESBYTERIAN Component - 01
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Smoke barrier doors shall be a minimum of 1-3/4 inches thick, solid-bonded wood core or equivalent with self-closing or automatic-closing devices in accordance with 21.2.2.4. Latching hardware is not required. Doors are not required to swing in the direction of egress travel.
21.3.7.9, 21.3.7.10
Observations:
Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors equipped with latching devices in one instance, affecting two of thirteen smoke compartments.
Findings include:
1. Observation on November 4, 2024, at 10:30 a.m., revealed the smoke doors at the 10 D entrance, next to room F 1041, would not latch when tested.
Interview with Facility Staff on November 4, 2024, at 11:00 a.m., confirmed the above listed deficency.
Plan of Correction:Smoke doors were repaired so that they close and latch as required. Compliance with this corrective action will be reported to the hospital safety committee and tracked as part of the Quality Assurance Program. Ongoing compliance will be monitored during hazard surveillance rounds.
|