Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID #22851501
Component 01
St. Clare Medical Building
Based on a Relicensure Survey completed on March 13, 2024, it was determined Ambulatory Surgery Center at St. Mary, LLC 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 (222) fire resistive building, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Hazardous Areas - Enclosure
Name - CLASS C ASF Component - 01
Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7
Observations:
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of hazardous areas, in sprinklered locations, affecting one of four levels.
Findings include:
Observation on March 13, 2024, at 10:15 a.m., revealed, on the first floor, electrical transformer room had an unsealed penetration around MC wires.
Exit Interview with the Administrator and Maintenance Director on March 13, 2024, at 11:10 a.m., confirmed the unsealed penetration.
Plan of Correction:The penetrations were reviewed and discussed with hospital building management. They were repaired and closd with Hilti FS1 Fire Caulk UL System W-L-8071 the day following the inspection. It is the responsibility of the administrator to ensure the correction is carried out and randomized inspections continue for penetrations.
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier
Name - CLASS C ASF 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 smoke barrier walls free of unsealed penetrations, affecting one of four levels.
Findings include:
Observation on March 13, 2024, at 9:40 a.m., revealed an open penetration above the smoke doors in pre-op, right side.
Exit Interview with the Administrator and Maintenance Director on March 13, 2024, at 11:10 a.m., confirmed the penetration.
Plan of Correction:The penetrations were reviewed and discussed with hospital building management. They were repaired and closd with Hilti FS1 Fire Caulk UL System W-L-8071 the day following the inspection. It is the responsibility of the administrator to ensure the correction is carried out and randomized inspections continue for penetrations.
28 Pa. Code § 569.2 STANDARD
HVAC
Name - CLASS C ASF Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting one of four levels.
Findings include:
Document review on March 13, 2024, at 9:00 a.m., revealed the facility lacked documentation indicating a four-year exercise of the fire/smoke dampers was performed.
Exit Interview with the Administrator and Maintenance Director on March 13, 2024, at 11:10 a.m., confirmed the missing documentation.
Plan of Correction:Following the survey, it was determined that a transition to new building management company led to confusion about responsibilities. On 4/1/24, hospital plant operations manager met with building management to confirm responsibilities moving forward. Damper inspection will be completed by month end. It is the responsibility of the administrator to ensure this is completed and scheduled thereafter.
28 Pa. Code § 569.2 STANDARD
Electrical Systems - Other
Name - CLASS C ASF Component - 01
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Observations:
Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of four levels.
Findings include:
Observation on March 13, 2024, at 10:20 a.m., revealed, on the first floor, in the electrical transfer switch room, a junction box was missing its cover plate, exposing the inner wiring.
Exit Interview with the Administrator and Maintenance Director on March 13, 2024, at 11:10 a.m., confirmed the exposed wiring.
Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.
Plan of Correction:This was discussed with hospital plant operations management and the cover plate was observed and confirmed to be replaced as of 4/2/24. It is the responsibility of the administrator to ensure the cover plate remains in place.
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