Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 06001500
Component 01
Main Building
Based on a revisit to a Relicensure Survey completed on January 18, 2024, it was determined that Mount Nittany Health Surgical Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - MAIN BUILDING 01 Component - 01
Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44
Observations:
Based on observation and interview, it was determined the facility failed to maintain one tenant separation wall, affecting one of three floors.
Findings include:
1. Observation on January 18, 2024, at 1:06 p.m., revealed the tenant separation wall was incomplete, located above the Staff Entrance door.
Exit interview on January 18, 2024, between 1:20 p.m., and 1:25 p.m., with the Facilities Manager, confirmed the tenant separation wall deficiency.
At the time of the revisit this deficency remained.
Plan of Correction:Tom Bradford Heating -- Installed the Mineral Wool and Fire Caulking per 3Ms Engineering Judgment Instructions, (on file at MNSC).
Completion Date 3/11/2024
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier Doors
Name - MAIN BUILDING 01 Component - 01
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Smoke barrier doors shall be a minimum of 1-3/4 inches thick, solid-bonded wood core or equivalent with self-closing or automatic-closing devices in accordance with 21.2.2.4. Latching hardware is not required. Doors are not required to swing in the direction of egress travel.
21.3.7.9, 21.3.7.10
Observations:
Based on observation and interview, it was determined the facility failed to maintain one set of smoke barrier separation doors, affecting one of three floors.
Findings include:
1. Observation on January 18, 2024, at 12:55 p.m., revealed the smoke barrier separation doors, located closest to the Nurse Station, did not fully latch, and the distance between the doors exceeded one-eighth-inch.
Exit interview on January 18, 2024, between 1:20 p.m., and 1:25 p.m., with the Facilities Manager, confirmed the smoke barrier separation door deficiency.
At the time of the revisit this deficency remained.
Plan of Correction:Builders Hardware Installed the Door Gasket Material on 3/12/2024. Door Latching was Repaired previously, this is completed at this time.
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