Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID #01421500
Component 01
Suite 270
Based on a Relicensure Survey completed on December 20, 2022, it was determined that Apple Hill Surgical Center Partners was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a two-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered. The facility is located on the 2nd floor.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Laundry and Rubbish Chutes and Incinerators
Name - MAIN BUILDING Component - 01
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
Rubbish chutes are installed per section 9.5.
*Walls, partitions, and inlet openings meet the requirements of 8.3.
*Doors of chutes open to a room designed exclusively for accessing the chute opening.
*Room used for accessing the chute opening(s) are separated from other spaces per 8.7.
*Chutes shall be permitted to open into rooms not exceeding 400 cubic feet in size if the room is sprinkler protected and the room is not used for storage.
OR
*Existing installations having properly enclosed and maintained chute openings shall be permitted to have inlets open to a corridor or normally occupied space.
21.5.4, 9.5, NFPA 82
Observations:
Based on observation and interview, it was determined the facility failed to maintain the linen chute terminus door, to self-close, in 1 of 3 smoke zones within the component.
Findings include:
1. Observation on December 20, 2022, at 12:40 PM, revealed the linen chute terminus room door failed to self-close.
Interview at the time of the exit conference with the Director of Facilities and the Administrator on December 20, 2022, at 12:45 PM, confirmed the chute terminus room door failed to self-close.
Plan of Correction:Plan of Correction:
Work order #2022240590 was entered on December 21, 2022, to order a new self-closing door. Corrective actions are anticipated to be completed on or around March 21, 2023. The rating of the area will be maintained.
Please note because of current supply chain issues, expected delivery of the door may extend beyond the expected date of compliance.
Systemic Changes Implemented to Prevent Recurrence of the Deficiencies:
An Environment of Care (EOC) Preventive Maintenance work order was entered December 30, 2022, to include a monthly inspection for proper self-close of the door.
Person Responsible for Corrective Actions:
Manager – Engineering
Method for Monitoring:
EOC PM tasks as described above.
Frequency of Monitoring:
Monthly
Measure of Effectiveness:
100% of PM activities will demonstrate compliance with NFPA Standards.
Corrective actions will be determined effective after three consecutive months of 100% compliance. After sustained compliance is achieved, monitoring will transition to checks completed during Environment of Care Rounds. Monitoring results will be reported monthly to the Surgery Center's Quality Management Council (QMC) by the Manager – Accreditation and Licensure.
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