QA Investigation Results

Pennsylvania Department of Health
CENTER FOR SAME DAY SURGERY AT WILKES-BARRE GENERAL HOSPITAL
Building Inspection Results

CENTER FOR SAME DAY SURGERY AT WILKES-BARRE GENERAL HOSPITAL
Building Inspection Results For:


There are  16 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - MAIN BUILDING 01 Component - 01

Facility ID# 12831500
Component 01
Building 01

Based on a Relicensure Survey completed on June 5, 2018, it was determined the Center for Same Day Surgery at Wilkes-Barre General Hospital, 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 II (000), unprotected noncombustible building, that is fully sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Exit Signage

Name - MAIN BUILDING 01 Component - 01
Exit Signage
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
20.2.10, 21.2.10, 7.10

Observations:

Based on observation and interview, it was determined the facility failed to maintain one illuminated exit sign, affecting one of two smoke compartments.

Findings include:

1. Observation on June 5, 2018, at 10:16 a.m., revealed the exit sign, located within the Main Lobby area, was partially obscured.

Exit interview with the Facilities Manager between 10:30 a.m. and 10:40 a.m., on June 5, 2018, confirmed the exit signage deficiency.




Plan of Correction:

Engineering moved the exit sign to an area that it is not obscured.

Will be monitored on quarterly environmental inspections of the facility. If same issue reoccurs engineering will be notified to correct the problem.


28 Pa. Code 569.2 STANDARD
Hazardous Areas - Enclosure

Name - MAIN BUILDING 01 Component - 01
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

Observations:

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of two smoke compartments.

Findings include:

1. Observation on June 5, 2018, at 10:03 a.m., revealed the Decontamination Room door was warped and lacked smoke-tight integrity.

Exit interview with the Facilities Manager between 10:30 a.m. and 10:40 a.m., on June 5, 2018, confirmed the hazardous area enclosure deficiency.




Plan of Correction:

Engineering installed a seal around the frame of the door to create smoke tight integrity.

Will be monitored on quarterly environmental inspections of the facility. If same issue reoccurs engineering will be notified to correct the problem.


28 Pa. Code 569.2 STANDARD
Portable Fire Extinguishers

Name - MAIN BUILDING 01 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 observation and interview, it was determined the facility failed to maintain one portable fire extinguisher, affecting one of two smoke compartments.

Findings include:

1. Observation on June 5, 2018, at 9:49 a.m., revealed the fire extinguisher cabinet bulb, closest to the reception area, was not illuminated.

Exit interview with the Facilities Manager between 10:30 a.m. and 10:40 a.m., on June 5, 2018, confirmed the portable fire extinguisher deficiency.




Plan of Correction:

The light bulb was replaced and in now functioning correctly.

Will be monitored on quarterly environmental inspections of the facility. If same issue reoccurs engineering will be notified to correct the problem.