Initial Comments:
Name - REPLACEMENT ASC Component - 10
ID# 06181500
Component 10
Replacement ASC
Based on a Relicensure Survey completed on February 28, 2024, it was determined that GI-ASC, LLC was not in compliance with the following requirements of the Life Safety Code for a New Ambulatory health care occupancy.
This is a one story, Type II (000), unprotected non-combustible building, that is fully sprinklered.
Approved as a Class B Ambulatory Surgical Facility.
Plan of Correction:
NFPA 101 STANDARD
HVAC
Name - REPLACEMENT ASC Component - 10
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Based on document review, observation, and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting the entire facility.
Findings include:
1. Document review on February 28, 2024, at 8:30 a.m., revealed the facility lacked documentation indicating required testing/inspection of the fire/smoke dampers was performed 1-year after installation.
Exit Interview with the Administrator on February 28, 2024, at 10:35 a.m., confirmed damper inspection documentation was unavailable at time of the survey.
2. Observation on February 28, 2024, at 9:45 a.m., revealed, in the anesthesia room, excessive fire caulk was installed around the damper perimeter along the duct, which could interfere with damper operation.
Exit Interview with the Administrator on February 28, 2024, at 10:35 a.m., confirmed the excessive fire caulk.
Plan of Correction:1. Inspection of fire/smoke damper will be completed as required by March 22, 2024. Documentation will be available for review.
2. Excessive fire caulk around the damper perimeter along the duct will be removed as required by March 16,2024.Documentation will be available for review.
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