QA Investigation Results

Pennsylvania Department of Health
DERMATOLOGIC SURGICENTER - PHILADLEPHIA
Building Inspection Results

DERMATOLOGIC SURGICENTER - PHILADLEPHIA
Building Inspection Results For:


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Initial Comments:
Name - CLASS B ASF Component - 01

Facility ID #04841500
Component 01

Based on a Relicensure Survey completed on January 29, 2019, it was determined that Dermatologic Surgery Center - Philadelphia was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a four-story, Type V (111), protected wood frame construction, with a basement, which is non-sprinklered.

Approved as a Class B Ambulatory Surgical Facility (ASF).


Plan of Correction:




28 Pa. Code 569.2 STANDARD
Emergency Lighting

Name - CLASS B ASF Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9

Observations:
Based on observation and interview it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition on one of four floors.

Findings include:

1. Observation on January 29, 2019, at 9:15 am, revealed, by front emergency exit door, the battery back-up lighting and remote fixtures failed to illuminate when tested.

Interview with the office manager at the exit conference on January 29, 2019, at 10:50 am, confirmed the battery back-up lights failed to illuminate when tested.




Plan of Correction:

An electrician will be called to replace the battery in the backup lighting fixture and assure illumination. Lighting will be visually inspected monthly by an assigned staff member to ensure they are functioning properly. The lights will also be tested yearly for 90 min. An assigned staff member will keep a log of all testing.


28 Pa. Code 569.2 STANDARD
Portable Fire Extinguishers

Name - CLASS B ASF Component - 01
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10

Observations:
Based on document review and interview, it was determined the facility failed to ensure inspection of portable fire extinguishers were performed by certified personnel, affecting the ambulatory surgery facility.

Findings Include:

1. Document review on January 29, 2019, at 8:55 am, revealed documentation was unavailable verifying entities providing servicing and recharging of portable fire extinguishers had attended required training, and were credentialed.

Interview at the exit conference with the Office Manager on January 29, 2019, at 10:50 am confirmed verification of portable fire extinguisher training was not available at the time of inspection.




Plan of Correction:

The company who performs our fire inspections will be notified to provide verification of training and credentialing of their employees. This will be current and up to date. Copies will be kept in our facility. With our yearly contract checks, an assigned employee will ensure certificates are current and up to date.


28 Pa. Code 569.2 STANDARD
Subdivision of Building - Smoke Barrier

Name - CLASS B ASF Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5

Observations:

Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of smoke barrier walls on one of four floors.

Findings include:

1. Observation on January 29, 2019, at 9:50 am, revealed above the fire door at the examination room, an unsealed penetration around MC cable.

Interview at the exit conference with the Office Manager on January 29, 2019, at 10:50 am confirmed the unsealed penetration.









Plan of Correction:

The penetration around the MC cable above the fire door of the exam room will be sealed with properly rated fire retardant material (3M CP 25 WB). Upon completion, the Assistant Medical Director will visually inspect to ensure completeness. All materials used for fire system repairs will be confirmed by the manufacturer as appropriate for use with a UL approved through penetration fire stop system.


28 Pa. Code 569.2 STANDARD
Electrical Systems - Other

Name - CLASS B ASF Component - 01
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.

Observations:

Based on observation and interview, it was determined the facility failed to protect electrical wiring on one of four floors.

Findings include:

1. Observation on January 29, 2019, at 9:45 am, revealed, in the access panel located in the corridor behind the reception area, an unsecured electrical box, with a missing cover plate and exposed wiring.

Interview with the office manager at the exit conference on January 29, 2019, at 10:50 am, confirmed the unsecured electrical box and exposed wiring.





Plan of Correction:

The unsecured electrical box with missing cover plate and exposed wired will be repaired or replaced. Upon completion, the Assistant Medical Director will inspect to ensure completeness. A monthly check of the electrical receptacles will be maintained by an assigned employee.