Initial Comments:Based on an Emergency Preparedness Survey completed on July 31, 2024, at Wellspan Dr. Roy A. Himelfarb Surgery Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01Facility ID #11401501Component 01 Suite 100 Based on a Recertification/Relicensure Survey completed on July 31, 2024, it was determined that Wellspan Dr. Roy A. Himelfarb Surgery Center 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 two-story, Type II (111), protected noncombustible structure, with a basement, which is fully sprinklered.
Plan of Correction:
NFPA 101 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 document review and interview, it was determined the facility failed to provide a distinct waiting room for the ambulatory surgical center patients within the confines of a 1-hour tenant separation wall, in accordance with 42 CFR 416.2, 42 CFR 416.44(b), and CMS Memorandum S&;C-10-20-ASC, dated May 21, 2010.
Findings include:
1. Interview on August 6, 2024, at 11:15 AM revealed the waiting room for surgical patients and visitors was not separated from other entities and occupancy types by a 1-hour fire rated tenant separation wall.
Interview with the Inclusion Champion Accreditation and Licensure on August 6, 2024, at 11:15 AM, confirmed the waiting room was not separated from other entities.
Plan of Correction:A letter requesting a waiver will be sent to the Harrisburg Field Office on 8/14/2024. There is not a 1-hour firewall between the waiting room of the surgery center and the hallway of the building. The Dr. Roy A. Himelfarb Surgery Center was built in 2000 and opened January 2021. The surgery center is a fully sprinklered area, thus ensuring the safety of patients and families in case of fire.
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