|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.
184.108.40.206, 220.127.116.11, 18.104.22.168, 22.214.171.124,42 CFR 416.44
Name: HARLEYSVILLE OUTPATIENT CENTER - 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 the entire facility.
1. Observation on January 16, 2020, between 10:15 am and 10:30 am, revealed unsealed penetrations of the tenant separation wall in the following locations:
a. 10:15 am, in the corridor above staff entrance doors, around MC cables;
b. 10:30 am, in the corridor across from mechanical room, open hole.
Interview at the exit conference with the Administrator and Director of Nursing on January 16, 2020, at 11:35 am, confirmed the unsealed penetrations.
| ||Plan of Correction - To be completed: 01/27/2020|
Penetrations will be sealed by Feb.7, 2020 with an approved through penetration fire stop system. around all MC cables and wires. This will restore the integrity of the UL CEG-8-11-83 rating of the 1 hour fire wall. The facility will maintain the tenant separation.
The Exec. Director will randomly inspect all fire walls on a quarterly basis and as needed when any work is completed to ensure all penetrations are sealed properly.