Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID #10581500
Component 01
Main Building
Based on a Relicensure Survey completed on April 3, 2025, it was determined CHOP Bucks Specialty Care and Ambulatory Surgery Center was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a one-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - CLASS C ASF Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on observation and interview, the facility failed to maintain the sprinkler system, affecting the entire facility.
Findings include:
Observation on April 3, 2025, at 12:20 p.m., revealed a sprinkler escutcheon was missing in the ESD 211 closet.
Exit interview with the facilities regulatory coordinator, the maintenance supervisor, and the administrator on April 3, 2025, at 1:45 p.m., confirmed the missing escutcheon.
Plan of Correction:Observation #353 - The sprinkler escutcheon has been installed in the ESD 211 closet. It is unknown why this escutcheon was not in place. To prevent a reoccurrence, staff will be retrained on sprinkler inspections while performing rounds in the building by 4/25/25. Sprinkler escutcheons are to be tight to the ceiling with no visible gaps.
28 Pa. Code § 569.2 STANDARD
Utilities - Gas and Electric
Name - CLASS C ASF Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2
Observations:
Based on observation and interview, the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of two electrical closets.
Findings include:
Observation on April 3, 2025, at 12:33 p.m., revealed storage items blocking the electrical panels in the main electrical closet.
Exit interview with the facilities regulatory coordinator, the maintenance supervisor, and the administrator on April 3, 2025, at 1:45 p.m., confirmed the blocked access to the electrical panels.
Plan of Correction:Observation #511 - The filters that were stored in front of the of the electrical panel in the electrical closet have been relocated providing for clear access to the panel. Staff temporarily located these filters when they were delivered with the intention of relocating. To prevent a re-occurence, staff will be retrained on clearance requirements for electrical equipment and panels by 4/25/25.
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