UPMC Presbyterian Renal Unit

“Multiple Occupancies CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 44386 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.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 50030 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.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 44386 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.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 44386 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.”

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 32773 Based on observations (OBS), review of manufacturers recommendations and staff (EMP) interview the agency failed to ensure the test strips for total water hardness had not expired during one of one observational one (1) of ten (10) observations made. OBS #1 Findings include: OBS #1 of the water treatment room on 10/8/24, at 11:37 a.m. with EMP1 Registered Nurse Educator and EMP2 Senior Clinician, revealed nine boxes of Serim water hardness test strips that expired 7/31/24. Review of the manufacturers recommendations of Serim water hardness test strips on 10/8/24, at 11:38 a.m. indicated do not use a test strip (from an opened or unopened) after the expiration date. During an interview on 10/9/24, at 2:23 p. m. EMP 2 Senior Clinician confirmed the above findings.”