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Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the common (fire) wall separations, on two of three levels within this facility (Havertown Campus).

Findings include:

1. Observations made on April 3, 2017, between 10:35 am and 1:50 pm, revealed deficiencies of the common (fire) wall separation at the following locations:

a. 10:35 am, third floor above the fire door seperating the Child Guidance Building from Kindred Hospital, there was a 2" inch copper pipe unsealed penetration;
b. 1:35 pm, first floor Child Guidance waiting room, left of check-in, there was an unsealed duct penetration;
c. 1:40 pm, first floor Child Guidance main entrance, above the door, there was an unsealed penetration;
d. 1:50 pm, first floor clean linen room door within the separation, there were missing screws to secure the rated vision panel.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the deficiencies of the common (fire) wall separations in the above named locations.


2. Observation made on April 3, 2017 at 1:20 pm, revealed the first floor common (fire) wall connector bridge seperating the Child Guidance Building from Kindred Hospital had a gap between the double doors in excess of 1/8" inch.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the fire doors were not resistive to the passage of smoke.

Based on observation and interview, it was determined the facility failed to ensure there were no obstructions in the means of egress, at two of five exit discharges within this facility (Havertown Campus).

Findings Include:

1. Observations made on April 3, 2017, between 11:31 am and 1:15 pm, revealed exit discharge doors that would not open in the following locations:

a. 11:31 am, basement cafeteria exit discharge door (right side double door).
b. 1:15 pm, 1st floor stairtower #1 exit discharge door (right side double door).

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the exit discharge doors would not open.

Based on observation and interview, it was determined the facility failed to ensure hazardous areas were maintained with a smoke tight resistance in sprinklered locations, on one of three levels within this facility (Havertown Campus).

Findings include:

1. Observation made on April 3, 2017, at 11:25 am, revealed the basement kitchen dry storage room door (next to the sinks) failed to positively latch when tested.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the door failed to positively self-latch.

Based on document review and interview, it was determined the facility failed to ensure the fire alarm system was inspected at required intervals, on three of three levels within this facility (Havertown Campus).

Findings include:

1. Document reviewed on April 3, 2017, between 8:00 am and 10:00 am, revealed the semi-annual fire alarm inspection and testing reports were not available.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the lack of a semi-annual fire alarm inspection and testing documentation.

Based on observation and interview, it was determined the facility failed to ensure buildings classified as fully sprinklered maintain complete automatic sprinkler protection, on one of three levels within this facility (Havertown Campus).

Findings:

1. Observation made on April 3, 2017, at 11:30 am, revealed within the second floor mechanical room, duct AHU# 6 measuring greater than five feet in width lacked automatic sprinkler protection beneath the duct. The duct exceeds the maximum allowance of 4 feet.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the area lacked sprinkler protection.

Based on observation and interview, it was determined the facility failed to ensure the automatic sprinkler system was maintained without obstructions within a smoke tight assembly, on three of three levels within this facility (Havertown Campus).

Findings include:

1. Observation made on April 3, 2017, at 10:41 am, revealed the basement corridor leading to the loading dock, sprinkler system was not maintained with a smoke tight ceiling assembly. There were unsealed penetrations.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the openings in the ceiling assembly.

2. Observation made on April 3, 2017, at 11:24 am, revealed basement kitchen walk-in freezer had storage less than 18 inches from the sprinkler.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed storage too close to the sprinkler.

3. Observation made on April 3, 2017, at 1:00 pm, revealed the basement elevator machine room had a sprinkler covered with dirt & debris.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the sprinkler covered with dirt & debris.

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers were secured, on one of three levels within this facility (Havertown Campus).

Findings include:

1. Observation made on April 3, 2017, at 10:52 am, revealed the basement electrical room (right wall) had an unsecured portable fire extinguisher.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the free standing portable fire extinguisher.

Based on observation and interview, it was determined the facility failed to ensure corridor doors positively latched into the door frame, on one of three levels within this facility (Havertown Campus).

Findings include:

1. Observations made on April 3, 2017, at 10:48 am, revealed unsealed penetrations in the basement electrical room, near the single door handle (both sides).

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed an unsealed penetration.


2. Observation made on April 3, 2017 at 11:10 am, revealed the 3rd floor equipment storage room corridor door, across from room 315, failed to positively latch into the door frame due to missing door hardware.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the missing door hardware.

Based on observation and interview, it was determined the facility failed to maintain smoke barriers with a fire resistance rating, on one of three levels within this facility (Havertown Campus).

Findings include:

1. Observation made on April 3, 2017, at 10:50 am, revealed above the suspended ceiling within the 3rd floor clean supply room there were two partially sealed penetrations of the smoke barrier wall around a drywall patch and a structural steel beam

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the smoke barrier penetrations.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors with a smoke tight resistance, on one of four levels within this facility (Havertown Campus).

Findings include

1. Observation made on April 3, 2017, at 11:00 am, revealed the third floor Educators office corridor door, which is a part of the smoke barrier, lacks a self-closure.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the lack of a self-closing device on the smoke barrier door.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was protected, on two of three levels within this facility (Havertown Campus).

Findings Include:

1. Observations made on April 3, 2017, between 10:47 am and 1:22 pm, revealed exposed electrical wiring in the following locations:

a. 10:47 am, basement, above the electrical room single door, had an open junction box;
b. 1:22 pm, 1st floor, above the Child Guidance double fire-rated doors, had open armour cables.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the exposed electrical wiring.

Based on document review and interview, it was determined the facility lacked documentation verifying required testing of battery back-up lighting, on one of three levels within this facility (Havertown Campus).

Findings include:

1. Document review on April 3, 2017, between 8:00 am and 10:00 am, revealed the first floor mechanical space lacked documentation of monthly 30 second and annual 90 minute testing of battery back-up lighting.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed the lack of documentation for testing of battery back-up lighting.

Based on document review and interview, it was determined the facility failed to maintain required testing of the emergency generator within this facility (Havertown Campus).

Findings include:

1. Documentation reviewed on April 3, 2017, between 8:00 am and 10:00 am, revealed a lack of weekly electrolyte and monthly specific gravity inspection and testing for the emergency generator's battery.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed documentation was unavailable for testing of emergency generator components.

Based on observation and interview, it was determined the facility failed to ensure the removal of temporary wiring on one of four levels within this facility (Havertown Campus).

Findings Include:

1. Observation made on April 3, 2017 at 1:10 pm, revealed abandoned contractor's lighting was installed above the suspended ceiling within first floor administrative and clerical office areas.

Refer to the 2011 edition of NFPA 70 - National Electrical Code.

Interview with the Chief Executive Officer and the Operations Manager, at the exit conference, on April 3, 2017, at 2:35 pm, confirmed temporary wiring installation.