Initial Comments:
Name - AMBULATORY SURGERY CENTER LOCATED ON THE FIRST LEV Component - 01
Facility ID # 51271501
Component 01
Main Building
Based on a Relicensure completed on November 12, 2025, it was determined that Wellspan Citygate Surgery Center, Llc was not in compliance with the following requirements of the Life Safety Code for a new ambulatory health care occupancy.
This is a two-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - AMBULATORY SURGERY CENTER LOCATED ON THE FIRST LEV 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 hazardous area rated doors to be within the allowed gap margin, and failed to install fire door hardware in accordance with manufacture's instructions, on one of one floor within the component.
Findings include:
1. Observation on November 12, 2025, at 11:20 AM, revealed Post Operation trash holding door had gaps exceeding 1/8-inch, on the hinge side.
Interview with the Supervisor Accreditation & Licensure, Faculty Services Regulatory Compliance Specialist and Facilities Technician on November 12, 2025, at 12:10 PM, confirmed the rated door had gaps exceeding the allowed gap margins.
2. Observation on November 12, 2025, between 11:26 AM and 11:40 AM, revealed fire-rated doors gap solution hardware was not installed in accordance with manufacture's instruction, at the following locations:
a. 11:26 AM, Soiled Utility Room 1067, Door B, lacked gasket, top;
b. 11:35 AM, Soiled Utility Room 1067, Door A, lacked gasket, top;
c. 11:40 AM, Medical Gas Room 1083, Door A, lacked gasket, hinge side.
Interview with the Supervisor Accreditation & Licensure, Faculty Services Regulatory Compliance Specialist and Facilities Technician on November 12, 2025, at 12:10 PM, confirmed the door gap solutions were improperly installed.
Plan of Correction:Plan of Correction:
1. On 11/13/25, work order # 2025489808 was entered to remediate the non-compliant door gaps in the Post Operation trash holding room 1119. The work order was completed on 11/25/2025.
2. On 11/13/25, work order # 2025489819 was entered to remediate the non-compliant door gap solution for both doors on Soiled Utility Room #1067. On 11/13/25, work order # 20254189823 was entered to remediate the non-compliant door gap solution on the Med Gas Manifold room #1083. On November 21, 2025, the Heck Construction company was onsite to inspect door gap solutions currently installed. Corrective actions, door adjustments, and repairs were completed on 11/25/25.
Systemic Changes Implemented to Prevent Recurrence of the Deficiencies:
A Preventive Maintenance (PM) work order will be created in the Computerized Maintenance Management System (CMMS) by 12/5/25 to perform 5 random inspections for door gap compliance per month.
Koffel Compliance, fire protection engineers, will complete an annual compliance assessment of smoke and fire rated doors in March 2026.
Person Responsible for Corrective Actions:
Manager – Engineering
Method for Monitoring:
EOC Preventative Maintenance (PM) tasks as described above.
Frequency of Monitoring:
Monthly
Measure of Effectiveness:
100% of Preventive Maintenance (PM) activities will demonstrate compliance with National Fire Protection Association (NFPA) standards. All non-compliant doors will be addressed by the manager of engineering to rectify. After three consecutive months of 100% compliance the action plan will be transitioned to yearly monitoring. The monthly monitoring results will be reported to the Surgery Center's Quality Committee by the Supervisor – Accreditation and Licensure.
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