Nursing Investigation Results -

Pennsylvania Department of Health
AMBULATORY SURGERY CENTER AT ST MARY, LLC, THE
Building Inspection Results

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AMBULATORY SURGERY CENTER AT ST MARY, LLC, THE
Inspection Results For:

There are  13 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
AMBULATORY SURGERY CENTER AT ST MARY, LLC, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: CLASS C ASF - Component: 01 - Tag: 0000


Facility ID #22851501
Component 01
St. Clare Medical Building

Based on a Relicensure Survey completed on February 25, 2020, it was determined Ambulatory Surgery Center At St. Mary, Llc was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a four-story, Type II (222) fire resistive structure, which is fully sprinklered.





 Plan of Correction:


28 Pa. Code 569.2 STANDARD Multiple Occupancies:State only Deficiency.
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
Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the one-hour fire resistance rating of tenant separation walls, affecting one of one tenant separation.

Findings include:

1. Observation on February 25, 2020, between 10:20 a.m. and 10:40 a.m., revealed unsealed penetrations of the tenant separation wall, in the following locations:

a. 10:20 a.m., above the exit door, by the DON office, around a white cable;
b. 10:40 a.m., above the exit door, by the data closet, around cable.

Interview at the exit conference with the Administrator and Maintenance Representative on February 25, 2020, at 11:30 a.m., confirmed the unsealed penetrations.







 Plan of Correction - To be completed: 02/26/2020

Immediately following the survey, Plant Operations sealed the identified penetrations with NFPA approved product and puddy per UL/cUL system number W-L-3122.

New policy "Above Ceiling Access Work Policy & Procedure" will be approved by Board of Managers in April 2020. Policy delineates process for work, guidelines for vendors, and responsibility of Executive Director and SMMC Plant Operations for follow through and inspection.

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