Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID# 10701500
Component 01
Based on a Relicensure Survey completed on February 19, 2025, it was determined Abington Memorial Hospital Endoscopy 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 (222), fire resistive builfing, that is fully sprinklered.
Approved as a Class B Ambulatory Surgical Facility.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Fire Drills
Name - CLASS B ASF Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7
Observations:
Based on document review and interview, it was determined the facility failed to properly document required fire drills, affecting the whole component.
Findings include:
Interview and document review on February 19, 2025, at 8:30 a.m., revealed the facility could not provide documentation logs that quarterly fire drills at suite G-23, on the ground floor, had been conducted to include active participation sign in sheets of suite G-23 1st shift staff, as follows:
a. 2nd quarter of 2024.
b. 3rd quarter of 2024.
c. 4th quarter of 2024.
Exit phone interview, with the Facilities O&M Manager on February 19, 2025, at 3:15 p.m., confirmed the facility could not provide documentation that fire drills had been conducted that include the G-23 staff, for the quarters listed above.
Plan of Correction:1. 2nd, 3rd, 4th quarter fire drills were sent to surveyor on 2/20/25 and the misunderstanding about drills was cleared up with our surveyor.
2. Going forward, we will continue to perform our units quarterly fire drills including active participation of G-23 1st shift staff with a sign-in sheet.
3. I will ensure that Plant Operations/Facilities Manager receives a copy of these sign-in sheets after each quarterly drill. I will also have copies on-site for review.
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