Pennsylvania Department of Health
LAUREL LASER & SURGERY CENTER, L.P.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LAUREL LASER & SURGERY CENTER, L.P. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID 11351500
Component 01
Main Building

Based on a Relicensure Survey completed on May 1, 2025, it was determined that Laurel Laser and Surgery Center, L.P. 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 V (000), unprotected, wood frame building, with a basement, that is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Subdivision of Building - Smoke Barrier:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, the facility failed to maintain smoke barriers in one of over twenty rooms.

Findings include:

Observation on May 1, 2025, at 12:30 p.m., revealed the facility failed to maintain smoke barrier requirements in the basement storage/supply room. Several penetrations around the electrical conduits and plumbing pipes as well as gaps along the ceiling/wall joint and beam pockets at the upper, inside corners were present that would allow the transfer of smoke.

Interview with the maintenance supervisor on May 1, 2025, at 12:30 p.m., confirmed several penetrations and gaps in the smoke barrier at the time of the survey.

Plan of Correction - To be completed: 05/30/2025

All penetrations in the basement storage/supply room around electrical conduits and plumbing pipes, as well as gaps along the ceiling, wall joints, and beam pockets will be sealed with an appropriate fire-rated caulking by the maintenance supervisor by May 30, 2025. These caulked areas will be visualized by the Clinical Director at time of project completion, and verified one month post-completion to ensure that the caulking remains intact. The maintenance supervisor will check annually to ensure that no new penetrations are developing.

28 Pa. Code § 569.2 STANDARD Electrical Systems -Essential Electric System:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, the facility failed to meet electrical system requirements for one of one generator.

Findings include:

Document review on May 1, 2025, at 10:33 a.m., revealed the facility was unable to provide battery conductance testing documentation for May and June of 2024.

Interview with the maintenance supervisor on May 1, 2025, at 10:33 a.m.., confirmed the facility could not provide the documentation at the time of the survey.

Plan of Correction - To be completed: 06/01/2025

The Clinical Director and maintenance supervisor will verify that the monthly battery conductance testing report is attached to the "Monthly Test Log" binder. This will be monitored for a period of 6 months, beginning in June 2025

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