QA Investigation Results

Pennsylvania Department of Health
COLONOSCOPY CENTER, SELLERSVILLE, THE
Building Inspection Results

COLONOSCOPY CENTER, SELLERSVILLE, THE
Building Inspection Results For:


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Initial Comments:
Name - CLASS B ASF Component - 01

Facility ID# 17151501
Component 01
Main Building

Based on a Relicensure Survey completed on September 5, 2018, it was determined that The Colonoscopy Center, Sellersville not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a one-story, Type V (000), unprotected wood frame construction, which is non-sprinklered.

Approved as a Class B Ambulatory Surgical Facility.






Plan of Correction:




28 Pa. Code 569.2 STANDARD
Fire Alarm System - Testing and Maintenance

Name - CLASS B ASF Component - 01
Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5

Observations:

Based on observation and interview, it was determined the facility failed to maintain the smoke detection system within a smoke tight assembly, in operable condition, affecting 3 of 32 rooms within the facility.

Findings include:

1. Observation made on September 5, 2018, at 9:45 am, revealed inside the break room, a smoke detector was detached from the suspended ceiling tile.

Interview at the exit conference with the Executive Director and the Operations Manager, on September 5, 2018, at 10:45 am, confirmed the smoke detector was not secured.


2. Observations made on September 5, 2018, between 10:14 am and 10:16 am, revealed approximately 2 - 4" inch gaps in suspended ceiling tiles near smoke detectors, in the following locations:

a. 10:14 am, inside the medical gas vacuum pump room, there were multiple pipe penetrations;
b. 10:16 am, inside the electrical room, there were multiple conduit penetrations.

Interview at the exit conference with the Executive Director and the Operations Manager, on September 5, 2018, at 10:45 am, confirmed the unsealed gaps in the above named locations.









Plan of Correction:

The smoke detector that was noted to be detached from the ceiling tile in the break room will be secured against the ceiling tile by tightening the metal ceiling joist attachment stringer that secures the smoke detector to the ceiling. Any opening that remains around the perimeter of the smoke detector will be friction packed with NFPA approved Owens Corning Thermafiber SAFB Professional Grade Mineral Wool batting to ensure a smoke-tight assembly that will comply with NFPA 72 National Fire Alarm and Signal Code.
Additionally, the gaps noted between the suspended ceiling tiles and the pipe and conduit penetrations will also be closed to ensure a smoke-tight assembly. Any large gaps will be closed by re-cutting new ceiling tiles to ensure a tighter fit around the perimeter of the pipe or conduit penetrations.

After re-cutting the new ceiling tiles, any small openings that remain will be friction packed around the pipe or conduit perimeter opening with the Owens Corning Thermafiber SAFB Mineral Wool to create the smoke-tight assembly required to comply with current NFPA 72 Codes. Any and all smaller gaps between pipe and conduit penetrations in both the Vacuum Pump and Electrical room will be friction packed with the above described mineral wool to ensure the smoke-tight assembly required. The described repairs will be completed by 10/5/18.

To ensure continued compliance, all smoke detectors that are installed in the facility and all pipe and conduit penetrations through the ceiling tiles will be checked for NFPA installation compliance utilizing a monthly smoke detector and ceiling penetration form.

This monthly inspection will be completed and initialed by The Operations Manager and/or Facility Administrator. This form will be filed and available for review by current and future PA Department of Health inspectors upon request.

To further ensure compliance, any contractor that performs any work on or around facility installed smoke detectors or pipe and conduit ceiling penetrations will be reminded of the current NFPA 72 regulations to which they must comply. The Facility Administrator and/or Operations Manager will inspect the work accomplished by the contractor prior to them exiting the facility.


28 Pa. Code 569.2 STANDARD
Fire Drills

Name - CLASS B ASF Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7

Observations:

Based on document review and interview, it was determined the facility failed to ensure fire drills were conducted at required intervals, affecting one of four required drills.

Findings include:

1. Document review on September 5, 2018, at 8:15 am, revealed the facility could not provide documentation a quarterly fire drill had been performed for the 2nd quarter of 2018.

Interview at the exit conference with the Executive Director and the Operations Manager, on September 5, 2018, at 10:45 am, confirmed the quarterly fire drill report was not available.






Plan of Correction:

Due to staff unavailability, the second quarter of 2018's Fire Drill which should have been conducted, completed and documented between April and June was postponed and was completed during the first week of July, missing the second quarter cut-off date by 1 week.

Going forward, the facility will ensure that all required fire drills are completed and documented within the specified "quarter" dates as regulated by The PA Department of Health.

To ensure compliance, the Operations Manager and/or Nurse Manager will select the fire drill date for the specific quarter and initial a chart that will be placed in front of the Fire-Drill Document Binder. This will ensure that each fire drill date occurs within the specific dates as regulated by The PA Department of Health. This chart will be easily accessed and visible to the personnel responsible for conducting the drills and will provide a reminder as to when the drills will need to be completed.

This chart will also be added to the facility's building maintenance monthly calendar and will be checked and initialed at the beginning of each month by the Operations Manager and Nurse Manager to assist in selecting an appropriate fire drill due-date that falls within the date guidelines set forth by The Pa Department of Health.

This chart will be created and placed in the Fire Drill Document Binder and Building Maintenance Calendar by 10/5/2018.