Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 12831500
Component 01
Building 01
Based on a Relicensure Survey completed on June 5, 2023, it was determined that Center for Same Day Surgery at Wilkes-Barre General 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, noncombustible structure that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Vertical Openings - Enclosure
Name - MAIN BUILDING 01 Component - 01
Vertical Openings - Enclosure
2012 EXISTING
Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Unenclosed openings which do not serve as a required means of egress are permitted.
3. Exit access stairs may be unenclosed if they meet the following conditions:
Two stories or less
a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1).
b. Total travel distance to outside does not exceed 100 feet.
Three stories or less
a. Occupant load per story does not exceed 15 people.
b. Building is sprinkler protected throughout per 9.7.1.1(1).
c. Building contains an automatic smoke detection system per 9.6.
d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building.
e. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain vertical openings, affecting four of four floors.
Findings include:
1. Observation on June 5, 2023, at 11:30 a.m., revealed the elevator machine room was open to the stair enclosure at the lower level.
Exit interview with facility representatives #1, and #2 on June 5, 2023, at 11:45 a.m., confirmed the open elevator machine room into the stair enclosure.
Plan of Correction:A contractor replaced the missing drywall sections between lower level of the staircase and the machine room in the ambulatory surgery center building on 6/22/2023.
The Chief Quality Officer and the interim facilities director added the staircase to the environment of care rounds conducted semi-annually to ensure that any future areas of concern are identified and addressed timely.
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - MAIN BUILDING 01 Component - 01
Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
Observations:
Based on observation and interview, it was determined the facility failed to maintain emergency generators, affecting the entire facility.
Findings include:
1. Observation on June 5, 2023, at 10:50 a.m., revealed the facility lacked an externally located emergency stop for the generator.
Exit interview with facility representatives #1 and #2 on June 5, 2023, at 11:35 a.m., confirmed the lack of an externally located emergency stop.
Plan of Correction:The facility secured a quote to install an external emergency stop on the ambulatory surgery center building generator. A purchase order has been issued and the contractor is securing the emergency stop product from the manufacturer. The emergency stop will be installed no later than August 4, 2023. A preventative maintenance check will be added to the facilities work order system to facilitate the testing of the generator's external emergency stop on a semi-annual basis.
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