QA Investigation Results

Pennsylvania Department of Health
DERMATOLOGIC SURGICENTER - PHILADELPHIA
Building Inspection Results

DERMATOLOGIC SURGICENTER - PHILADELPHIA
Building Inspection Results For:


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Initial Comments:
Name - CLASS B ASF Component - 01

Facility ID #04841500
Component 01

Based on a Relicensure Survey completed on March 16, 2021, it was determined Dermatologic Surgicenter - Philadelphia 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 42 CFR 416.44(b).

This is a four story, Type V (111), protected wood frame construction, with a basement, which is non-sprinklered.

Approved as a Class B Ambulatory Surgical Facility (ASF).




Plan of Correction:




NFPA 101 STANDARD
Means of Egress - General

Name - CLASS B ASF Component - 01
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:

Based on observation and interview, it was determined the facility failed to ensure paths of egress were continuously maintained free of obstructions, affecting one of five levels within the building.

Findings include:

1. Observation on March 16, 2021, at 11:25 a.m., revealed trash cans, a grill and a cooler, stored on the top landing of the Exit Stairs, on the Ambulatory Surgical Center (ASC) side of the building.

Exit Interview with the Administrator on March 16, 2021, at 12:00 p.m., confirmed the storage in the exit stairs.






Plan of Correction:

Items blocking the top landing of the exit stairs on the 4th floor have been moved. (Completed 3/17/2021).

The medical director, a physician, or their designee will visually inspect the area monthly to ensure the area remains unblocked an clear.

Documentation that visual inspection has been completed will be kept in our Emergency Preparedness Binder.


NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - CLASS B ASF Component - 01
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on document review and interview, it was determined the facility failed to ensure required testing was performed for fire alarm system components, affecting the entire component.

Findings include:

1. Document review on March 16, 2021, between 9:30 a.m. and 11:15 a.m., revealed the facility could not provide documentation smoke detector sensitivity testing had been performed during the December 23, 2019 annual fire alarm inspection.

Exit Interview with the Adminstrator on March 16, 2021, at 12:00 p.m., confirmed the missing documentation.






Plan of Correction:

We have spoken with the Life Safety Inspector and our Fire Alarm Company. On the next inspection date in July, documentation on the City of Philadelphia Certification for Fire Alarm Systems form will be enhanced to include a more detailed sensitivity report. This will be inclusive of each smoke detector showing that it is within its operating sensitivity range.

A printed report will be included and will be kept on file at the facility.

The Medical Director, Assistant Medical Director, or their designee will be responsible to make sure this report is obtained and filed.