Initial Comments:
Name - ASF Component - 01
Facility ID #20821501
Component 01
Main Building
Based on a Relicensure Survey completed on February 6, 2024, it was determined that Community Surgery & Laser Center, LLC was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).
This is a one-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Means of Egress Requirements - Other
Name - ASF Component - 01
Means of Egress Requirements - Other
List in the REMARKS section any LSC Section 20.2 and 21.2 Means of Egress Requirements that are not addressed by the provided S-tags, but are deficient.
20.2, 21.2
Observations:
Based on observation and interview, the facility failed to maintain evacuation diagrams for two of more than five evacuation diagrams.
Findings include:
Observation on February 6, 2024, between 10:59 a.m. and 11:09 a.m., revealed two of the evacuation diagrams did not contain a notation showing the location of the viewer on the diagram.
Ref: NFPA 170-11.2.4 and 11.3.2
Interview with the director of nursing on February 6, 2024, at 11:09 a.m., confirmed the above deficiency existed.
Plan of Correction:The two evacuation diagrams will be updated to show a notation of the location of the viewer on the diagram. All other diagrams were immediately reviewed by the center director or designee to ensure compliance.
Staff will receive an in-service regarding regulations that all exit/building floor maps must indicate a notation showing location of the viewer on the diagram. Audits will be completed monthly x 3 months by the center director or designee and then biyearly and placed on the General Safety-Fire-Security survey checklist.
28 Pa. Code § 569.2 STANDARD
Hazardous Areas - Enclosure
Name - ASF 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, the facility failed to maintain the fire barrier in one of one mechanical/ electrical room.
Findings include:
Observation on February 6, 2024, at 11:04 a.m., revealed the mechanical/ electrical room had a unsealed penetration around conduit.
Interview with the director of nursing on February 6, 2024, at 11:04 a.m., confirmed the unsealed penetration existed.
Plan of Correction:3M Firewall barrier putty was applied to the unsealed penetration conduit on 2/10/2024. All other penetrations were immediately audited by center director or designee to ensure compliance.
Staff will receive an in -service regarding regulation of the hazards areas that are identified with a fire door or a mechanical room without a fire door must have sealed penetrations. To ensure the deficient practice does not reoccur, any penetrations placed in the walls going forth behind a fire door or in the mechanical room will be preapproved by the center director or designee. Audits will be completed monthly x 3 months by the center director or designee and then biyearly and placed on the General Safety-Fire-Security survey checklist.
28 Pa. Code § 569.2 STANDARD
Electrical Systems - Receptacles
Name - ASF Component - 01
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.4.2 (NFPA 99)
Observations:
Based on observation and interview, the facility failed to install and maintain electrical outlets, per NFPA 70, for one of over 30 outlets.
Findings include:
Observation on February 6, 2024, at 10:52 a.m., revealed the receptacle next to the sink in the recovery room lacked ground fault circuit interrupter (GFCI) protection.
Interview with the director of nursing on February 6, 2024, at 10:52 a.m., confirmed the above electrical outlet was not GFCI-protected.
Plan of Correction:The electrical receptacle next to the Sink in the PACU will be changed to a ground fault circuit interrupter (GFCI) by 2/10/2024. All other outlets were immediately reviewed by center director or designee to ensure compliance.
Staff will receive an in-service regarding regulations that an outlet must be a GFCI within six feet to a water source. To ensure the deficient practice does not reoccur, any outlets added must be preapproved by the center director or designee. Audits will be completed monthly x 3 months by the center director or designee and then biyearly and placed on the General Safety-Fire-Security survey checklist.
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