QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - CLASS B ASF Component - 01

Facility ID# 10701500
Component 01

Based on a Relicensure Survey completed on March 26, 2019, it was determined that Abington Memorial Hospital Endoscopy 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 (222), fire resistive structure, which is fully sprinklered.

Approved as a Class B Ambulatory Surgical Facility.

Plan of Correction:

28 Pa. Code 569.2 STANDARD
Gas and Vacuum Systems - Other

Name - CLASS B ASF Component - 01
Gas and Vacuum Piped Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 5 (NFPA 99)


Based on observation and interview, it was determined the facility failed to maintain a fire resistance rating for medical gas system enclosures, affecting one of one medical gas room.

Findings include:

1. Observation on March 26, 2019, at 10:05 am, revealed, inside the medical gas room, the ceiling assembly did not have a fire resistance rating. The perimeter of the room lacked fire rated walls extending to the deck above.

Interview at the exit conference with the Director of Plant Operations and the Maintenance Director on March 26, 2019, at 10:30 am, confirmed the medical gas room lacked a rated ceiling.

~Refer to NFPA 99: 4.1 and 5.2

Plan of Correction:

The Director Plant Operations is responsible for the corrective action and ongoing compliance.

The Director Plant Operations contacted DOH Life Safety and it was determined plans had to be submitted and approved prior to correction of deficiency. Director Plan Operations met with architect to submit drawings to DOH. Drawings will be reviewed with DOH on or before April 30. Once drawings are approved, medical gas storage ceiling will be brought into compliance within two weeks.

Completion of repair reported to Director Regulatory Affairs and the Safety Committee.