Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 06511500
Component 01
Main Building
Based on a Relicensure Survey completed on April 19, 2023, it was determined that Paoli Surgery Center, Llc 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 II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier
Name - MAIN BUILDING 01 Component - 01
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:
Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls, affecting two of two smoke compartments within the component.
Findings include:
1. Observation on April 19, 2023, at 12:30 PM, revealed an unsealed smoke barrier penetration over the corridor double door, by the Nurses' Station to the sterile corridor, around an M/C cable.
Interview with the Director of Maintenance on April 19, 2023, at 12:30 PM, confirmed the unsealed penetration.
Plan of Correction:1. During the tour with the inspector, we identified a small penetration passing through a fire rated partition in the Pre-Op. The penetration was sealed at the time it was identified with a UL approved fire rated system # W-L-1148.
During monthly EOC rounds and above ceiling inspections, facilities will identify any deficiencies and correct immediately. All deficiencies will be documented, and reported to administration and at the quarterly safety meeting. When a deficiency is identified, we will increase above ceiling inspections in that area to twice a month to ensure above ceiling procedures are being followed.
|