QA Investigation Results

Pennsylvania Department of Health
FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER, LLC
Building Inspection Results

FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER, LLC
Building Inspection Results For:


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Initial Comments:
Name - FERTILITY PARTNERS OF PA SURGERY CENTER, LLC Component - 01

Facility ID# 24571501
Component 01
FERTILITY PARTNERS OF PA SURGERY CENTER, LLC

Based on a Relicensure Survey completed on May 22, 2018, it was determined that Fertility Partners of Pennsylvania Surgery Center was 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 II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.


Plan of Correction:




28 Pa. Code 569.2 STANDARD
Hazardous Areas - Enclosure

Name - FERTILITY PARTNERS OF PA SURGERY CENTER, LLC 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 hazardous area doors to be self-closing, in one of one smoke zone within the component.

Findings include:

1. Observation on May 22, 2018, at 2:32 PM revealed the door of the Soiled Utility Room was not on a self-closing device.

Interview at the time of the exit conference with the Office Manager on May 22, 2018, at 2:45 PM confirmed the door did not self-close.



Plan of Correction:

A local door company has been contacted and requested to assess the issue with the door closure. It was determined that a self-closing devise does not exist on the door.

The door company has ordered the necessary self-closing door device. The devise will be installed upon receipt of the part.

To ensure proper operation of the self-closing device on this door, as well as other doors existing within the facility, a visual inspection of each door will be performed and documented as part of the monthly visual checklist.

The monthly visual checklist will be presented to the Safety Committee quarterly for review and approval.

This corrected action will be completed by June 30, 2018.