QA Investigation Results

Pennsylvania Department of Health
CROZER ENDOSCOPY CENTER (A DEPT OF CROZER CHESTER MEDICAL CE
Building Inspection Results

CROZER ENDOSCOPY CENTER (A DEPT OF CROZER CHESTER MEDICAL CE
Building Inspection Results For:


There are  9 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - CLASS B ASF Component - 01

Facility ID# 23631501
Component 01

Based on a Relicensure Survey completed on September 26, 2018, it was determined that Crozer Endoscopy Center (a Dept Of Crozer Chester Medical 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 (000), unprotected non-combustible construction, which is fully sprinklered.



Plan of Correction:




28 Pa. Code 569.2 STANDARD
Hazardous Areas - Enclosure

Name - CLASS B 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, it was determined the facility failed to ensure that doors to hazardous area enclosures were positively latching, on one of 3 levels within this facility.

Findings include:

1. Observation made on September 26, 2018, at 9:20 am, revealed the fire rated door to the lower level boiler room failed to positively latch.

Interview at the exit conference with the Facility Director on September 26, 2018, at 9:50 am, confirmed the door failed to positively latch.





Plan of Correction:

The Property Manager has been made aware of the hardware issue and will repair by 10/30/18. Since this is outside the Endoscopy Suite on another floor, Facilities Management will continue to work with the Property Manager to inspect the doors for proper operation during routine safety tours.