Nursing Investigation Results -

Pennsylvania Department of Health
ORTHOPAEDIC SURGERY CENTER AT BRYN MAWR HOSPITAL
Building Inspection Results

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ORTHOPAEDIC SURGERY CENTER AT BRYN MAWR HOSPITAL
Inspection Results For:

There are  4 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.
ORTHOPAEDIC SURGERY CENTER AT BRYN MAWR HOSPITAL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: CLASS C ASF - Component: 01 - Tag: 0000


Facility ID# 24551501
Component 01
Main Building

Based on a Relicensure Survey completed on February 13, 2019, it was determined that Orthopaedic Surgery Center At Bryn Mawr Hospital 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 (000), unprotected non-combustible structure, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.




 Plan of Correction:


28 Pa. Code 569.2 STANDARD Subdivision of Building - Smoke Barrier:State only Deficiency.
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: CLASS C ASF - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to ensure smoke barrier walls were free of unsealed penetrations, affecting 2 of 2 smoke zones within the component.

Findings include:

1. Observation made on February 13, 2019, at 9:12 am, revealed on the 4th floor near recovery room #27, above the suspended ceiling at the sink area, there was an unsealed penetration in the smoke barrier wall around an electrical cable.

Interview at the exit conference with the Administrator on February 13, 2019, at 10:05 am, confirmed the unsealed penetration in the smoke barrier wall.




 Plan of Correction - To be completed: 02/13/2019

The Administrator is responsible to assure corrective actions are completed, monitored and sustained. The smoke barrier wall unsealed penetration near recovery room #27 above the suspended ceiling at the sink area was repaired at 1pm on 2/13/19. The fire system utilized to complete this repair was system # W-L-1054. Safety inspections will be completed when any installations or repairs occur in any fire or smoke barrier walls to ensure that any penetrations are repaired with an appropriate fire rated system. The Director of Facilities will report aggregate results of these inspections at quarterly Safety Meetings

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