Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID# 05421500
Component 01
Based on a Relicensure Survey completed on May 21, 2024, it was determined that Dermatologic Surgi Center - Drexel Hill 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 V (111), protected wood frame building, with a basement, that is not sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Building Construction Type and Height
Name - CLASS B ASF Component - 01
Building Construction Type and Height
Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively.
Construction Type
1 I (442), I (332), II (222), Any number of stories
II (111), III (211), IV (2HH), non-sprinklered or sprinklered
V (111)
2 II (000), III (200), V (000) One story non-sprinklered
Any number of stories sprinklered
Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met:
1. Such levels are under the control of the ambulatory health care occupancy.
2. Hazardous spaces are protected per section 8.7.
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain the building construction's fire resistance rating, affecting one of three levels within the building.
Findings include:
Observation made on May 21, 2024, at 9:40 a.m., revealed damaged suspended ceiling tiles in the basement. The facility construction has been classified with a minimum one hour fire resistance rating.
Exit Interview with the Administrator on May 21, 2024, at 10:30 a.m., confirmed the damaged suspended ceiling tiles.
Plan of Correction:There was one ceiling tile partially broken. This ceiling tile will be replaced sealed by August, 2024. Ceiling tiles will be inspected regularly, especially after maintenance repairs are completed.
28 Pa. Code § 569.2 STANDARD
Emergency Lighting
Name - CLASS B ASF Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
Observations:
Based on observation and interview, it was determined the facility failed to maintain emergency back-up lighting in operable condition, affecting one of three levels within this facility.
Observation made on May 21, 2024, between 8:30 a.m. and 10:30 a.m., revealed emergency backup lighting was not working in the following locations:
a. 9:55 a.m., In the hallway across from the Recovery room;
b. 10:05 a.m., Inside operating room #4
Exit Interview with the Administrator on May 21, 2024, at 10:30 a.m., confirmed the emergency backup lighting was not working in the above named locations.
Plan of Correction:These and all emergency lights are inspected on a regular basis. Please see the attached record. If the emergency lights are actually not functioning properly, Bradley and Sons will replace the units.
B & S will continue their inspections on a regular basis as has been done in the past.
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