QA Investigation Results

Pennsylvania Department of Health
BRYN MAWR MEDICAL SPECIALIST ENDOSCOPY ASSOCIATES LTD.
Building Inspection Results

BRYN MAWR MEDICAL SPECIALIST ENDOSCOPY ASSOCIATES LTD.
Building Inspection Results For:


There are  10 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - RELOCATED CLASS B ASF Component - 10

Facility ID# 17101501
Component 10
Medical Arts Pavilion

Based on a Relicensure Survey completed on April 18, 2019, it was determined that Bryn Mawr Medical Specialist Endoscopy Associates Ltd, 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 non-combustible construction, which is fully sprinklered.

Approved as a Class B Ambulatory Surgical Facility.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Multiple Occupancies

Name - RELOCATED CLASS B ASF Component - 10
Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44

Observations:
Based on observation and interview, it was determined the facility failed to maintain the one-hour fire resistance rating of tenant separation walls on one of four floors.

Findings include:

1. Observation made on April 18, 2019, at 10:50 am, revealed, above the suspended ceiling in Prep room 1, an unsealed penetrations of tenant separation wall around a pipe.

Interview at the exit conference with the Chief Executive Officer, Clinical Director and Building Maintenance Representative on April 18, 2019, at 11:45 am, confirmed the unsealed penetration.




Plan of Correction:

The sprinkler pipe above the suspended ceiling in Prep room 1 was inspected by our building engineer and noted to have a separation in the through-penetration firestop system that was originally installed. This separation was resealed using Through Penetration Firestop System Number W-L-1296 in accordance with UL 1479 certified fire stop system for use in 1 and 2 hour rated firewalls.

Measures we will take to ensure the problem does not recur:
1. The building engineer or designee will be contacted to perform a visual inspection of the tenant separation walls on a semi-annual basis, reporting all findings to the Administrative Director.
2. The Administrative Director will instruct all contractors, vendors and employees to seal any penetrations using a through-penetration firestop system.


28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - RELOCATED CLASS B ASF Component - 10
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Based on document review and interview, it was determined the facility failed to conduct required inspections of the sprinkler system, affecting the entire facility.

Findings include:

1. Document review April 18, 2019, at 9:40 am, revealed that the facility could not provide documentation showing a 5-year Obstruction Inspection was conducted.

Interview at the exit conference with the Chief Executive Officer, Clinical Director and Building Maintenance Representative on April 18, 2019, at 11:45 am, confirmed the missing documentation.




Plan of Correction:

5 year obstruction investigation of sprinkler system has been completed. Internal inspection at several locations of piping system was performed, all areas were clear of any obstruction. Valves in pump room were checked, operate freely, and are in good conditon, no obstructions. This inspection was performed by Keystone Fire Protection company on 4/19/2019. Water is supplied by Aqua through pump system.

Corrective measures were put in place to prevent any missed future inspections. Inspection due dates have been set by the ASC Director as a reminder. These reminders will be reviewed by the ASC Director annually, who will schedule maintenance and inspections accordingly through the building engineer. Inspections reports will be maintained by the ASC Director in a binder for review upon request.


28 Pa. Code 569.2 STANDARD
HVAC

Name - RELOCATED CLASS B ASF 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 and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting the entire facility.

Findings include:

Document review on April 18, 2019, at 9:50 am, revealed the facility lacked documentation that a four-year inspection of the fire/smoke fire dampers was performed.

Interview at the exit conference with the Chief Executive Officer, Clinical Director and Building Maintenance Representative on April 18, 2019, at 11:45 am, confirmed fire/smoke damper inspection documentation was not on-site during the time of the survey.




Plan of Correction:

4 year fire/smoke damper inspection has been contracted with Keystone Fire Protection and is scheduled to be performed during the week of 5/20/2019. Inspections will be performed throughout entire building at this time and will be scheduled on a 4 year interval moving forward. Certification and inspection report will be kept on file for review as needed.

Corrective measures were put in place to prevent any missed future inspections. Inspection due dates have been set by the ASC Director as a reminder. These reminders will be reviewed by the ASC Director annually, who will schedule maintenance and inspections accordingly through the building engineer. Inspections reports will be maintained by the ASC Director in a binder for review upon request.