Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44
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Observations:
Name: PENN MEDICINE AT RADNOR - Component: 10 - Tag: 0131
Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barriers separating occupancies, affecting the entire component.
Findings include:
1. Observation on May 10, 2023, at 9:15 am, revealed in the fire barrier across from the double doors from the Reception area, an open penetration by a data wire above the ceiling.
Exit interview with the Lead Maintenance Tech and the Associate Director of Facilities Operation on May 10, 2023, at 9:45 am, confirmed the open penetration.
| | Plan of Correction - To be completed: 06/30/2023
0131-Plan of correction:
Measures to be taken/or Systems to be altered to prevent reoccurrence:
The Penn Medicine Radnor Surgery Center, a facility of the Hospital of the University of Pennsylvania (RSC or Facility) took the following steps to address the deficiency noted.
The sealing of penetration fire barrier from the double doors of the reception area will be completed by a third party contractor by June 15, 2023. The penetration will be sealed using Hilti FS-One Max (W-L-3058).
The Facility will also require contractors to fill out above ceiling work permit before beginning work that requires penetration of smoke and fire barriers. The permit request will identify the company/individual doing the work and the location where the work is being done. Above ceiling working permits and the work will be inspected by Facility Operations, Property Manager and/or Maintenance staff upon completion. Operations and Maintenance staff will maintain a file of completed permits and conduct quarterly checks of work areas to verify compliance and that training records are on file.
Quality Monitoring Process:
The Associate Director of Ambulatory Facilities Operations for CPUP will create a building penetrations log sheet to be maintained by the Penn Medicine Radnor building engineer.
The Building Engineer and/ or Property Manager are responsible for auditing the log sheets and the file of completed permits on a quarterly basis to verify no fire walls have been penetrated and that the above ceiling work permits are completed. The Associate Director of Ambulatory Facility Operation will submit the results of the audit to Environment of Care Committee on a quarterly basis. The Environment of Care Committee will monitor compliance on a quarterly basis for 3 quarters of sustained compliance as part of ongoing quality assurance and performance improvement activities.
Responsible for Monitoring:
The Building Engineer or Property Manager are responsible for auditing the logs sheets and the file of completed permits on a quarterly basis to verify that fire walls have not been penetrated and that the above ceiling work permits are completed and on file.
The Environment of Care Committee will monitor compliance on a quarterly basis for 3 quarters of sustained compliance as part of ongoing quality assurance and performance improvement.
Completion date for Plan of Correction: June 30, 2023
Title of person responsible for compliance: Building engineer and property manager
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