Initial Comments:
Name - MAIN BUILDING Component - 02
Facility ID #17171501
Component 02
Main Building
Based on a Relicensure Survey completed on June 10, 2026, it was determined that Berks Ambulatory Surgery Center, Llc was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 28 Pa Code 569.2.
This is a one-story, Type V (000), unprotected wood frame structure, without a basement, which is not sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - MAIN BUILDING Component - 02
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:
Based on observation and interview, it was determined the facility failed to maintain the fire resistance of building separating common walls, affecting the entire component.
Findings include:
1. Observation on June 10, 2026, at 11:30 AM, revealed an unprotected penetration of the tenant separating wall, located above the ceiling, above the Oxygen Manifold Room, around a length of hard ductwork.
Interview with the Practice Manager on June 10, 2026, at 11:30 AM, confirmed the compromised fire resistance of the tenant separating wall.
2. Observation on June 10, 2026, at 12:00 PM, revealed two unprotected penetrations of the tenant separating wall, located above the suspended ceiling, above the Soiled Room: one empty cored hole, and one cored hole around a metal pipe.
Interview with the Practice Manager on June 10, 2026, at 12:00 PM, confirmed the compromised fire resistance of the tenant separating wall.
Plan of Correction:On June 24, 2026, the building maintenance crew is scheduled to repair the unprotected penetration of the tenant separating wall using fire-rated caulk and re-establish the integrity of the 1-hour fire barrier in the tenant separation wall, separating the health care occupancy from other tenants.
Repairs will be completed in the following areas:
-Above the ceiling, above the Oxygen Manifold Room around a length of hard ductwork
-Above the suspended ceiling, above the Soiled Room: one empty cored hole and one cored hole around a metal pipe.
The Administrator will confirm that this repair work is completed in accordance with Life Safety Regulations.
The Administrator is responsible for visually inspecting all repair work in the facility before the maintenance workers are dismissed, and for verifying that the fire rating of the separation wall is maintained, using the approved fire rating system outlined in Life Safety Code 28 Pa Code 569.2.
The Administrator will document repair work completed and verified in the Center's maintenance log and report this quarterly to the Safety Committee as part of the Center's Quality Assessment Plan.
|