QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - MAIN BUILDING 01 Component - 01

Facility ID# 06331500
Component 01
Main Building

Based on a Relicensure Survey completed on December 11, 2018, it was determined that Fairgrounds Surgical Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a three story, Type II (111), protected, noncombustible building, with a lower level parking garage and rooftop mechanical spaces, that is partially sprinklered.

Plan of Correction:

28 Pa. Code 569.2 STANDARD
Alcohol Based Hand Rub Dispenser (ABHR)

Name - MAIN BUILDING 01 Component - 01
Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces of aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* If floor is carpeted, the building is fully sprinkler protected
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section or
* ABHR is protected against inappropriate access,,, CFR 416.44


Based on observation and interview, it was determined the facility failed to install and maintain alcohol-based hand rub (ABHR) stations in multiple locations, affecting one of three floors.

Findings include:

1. Observation on December 11, 2018, between 9:40 a.m. and 9:58 a.m., revealed multiple alcohol-based hand rub stations were installed above carpeted areas, in multiple locations throughout the ambulatory surgical center portion of this component.

Exit interview with the facilities manager and the facility administrator between 10:15 a.m. and 10:25 a.m., on December 11, 2018, confirmed the ABHR deficiencies.

Plan of Correction:

Engineering will removed carpet below hand sanitizer and install none combustible flooring material (24" x 24" ) directly below dispenser(s) to catch material (this is in excess of the potential drip, fallout area of staff using the sanitizers). O.R. Department head will review with affected staff the proper use of hand sanitizing and assuring compliance. Director of Engineering will review requirements for installation of hand sanitizers based on requirements of 28 Pa. Code 569.2 STANDARD
Alcohol Based Hand Rub Dispenser (ABHR):
Name - MAIN BUILDING 01 Component - 01
Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with, with F&C Dept. / Engineering Dept./ and outside contractors during planning, renovations and or projects. Engineering will monitor area monthly, and verify no bleed over of sanitizing material and note compliance. (work to be complete by 01/31/19).