Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 24731501
Component 01
Building 01
Based on a Relicensure Survey completed on March 14, 2024, it was determined Azura Surgery Center Northeast Philadelphia 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 III (200), unprotected ordinary building, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Emergency Lighting
Name - CLASS C ASF Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
Observations:
Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was tested at required intervals, affecting one level.
Findings include:
Document review on March 14, 2024, at 9:00 a.m., revealed, documentation verifying an annual 90-minute test of the facility' s battery back-up lighting was not available at time of survey.
Exit interview with the Administrator on March 14, 2024, at 10:15 a.m., confirmed the missing documentation.
Plan of Correction:1. The Plan of Correction: Obtain documentation from vendor supporting the facilities 90-minutes battery backup lighting results that was completed on 7/28/2023.
2. A copy of the 90-minute emergency light testing is available at the facility and available for review.
3. Educated staff on 3/14/2024 on Policy EC603 Environment of Care Emergency and Exit Light Testing, documentation requirements needed for the 90-minute emergency testing. Documented proof will be captured by an attestation form signed by all staff present on site 3/14/2024. As well as all staff who are not present on 3/14/2024 will be educated upon his/her return to work at the facility.
4. 90-minute emergency lighting tests will be completed annually, reports available for surveyors upon request.
Responsible: Facility Administrator or Director of Nursing
Completion Date: 6/30/2024
28 Pa. Code § 569.2 STANDARD
Gas Equipment -Cylinder and Container Storage
Name - CLASS C ASF Component - 01
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of twenty-four floors.
Findings include:
Observation on March 14, 2024, at 10:40 a.m., revealed an unsecured oxygen cylinder, on the first floor in the manifold room.
Exit interview with the Administrator on March 14, 2024, at 10:15 a.m., confirmed the unsecured oxygen cylinder.
Plan of Correction:1. Plan of Correction: Oxygen cylinder immediately secured in an appropriate storage cart.
2. On 3/14/2024, Purchase from vendor of Cylinder cart lightweight with durable 6-inch, non-marring, semi-pneumatic wheels. Vendor also provided 2 additional carts to secure oxygen cylinders.
3. Educated staff on 3/14/2024 on Policy EC602 Environment of Care Medical Gas Cylinders and Manifold Systems, identify the proper way to secure oxygen cylinders. Documented proof will be captured by an attestation form signed by all staff present on 3/14/2024. As well as all staff who are not present on 3/14/2024 will be educated upon his/her return to work at the facility.
4. The facility plans to monitor weekly compliance checks and to make sure solutions are sustained by having the Facility Administrator or Director of Nursing survey Oxygen room weekly for 3 months. Starting 3/14/2024 until 6/30/2024. Compliance check results documentation will be reported quarterly to the Quality Assurance Performance Improvement/Governing Body/Medical Executive Meetings.
Responsible: Facility Administrator or Director of Nursing
Completion Date: 6/30/2024
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