QA Investigation Results

Pennsylvania Department of Health
CENTER FOR SAME DAY SURGERY AT WILKES-BARRE GENERAL HOSPITAL
Building Inspection Results

CENTER FOR SAME DAY SURGERY AT WILKES-BARRE GENERAL HOSPITAL
Building Inspection Results For:


There are  23 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - MAIN BUILDING 01 Component - 01

Facility ID# 12831500
Component 01
Main Building

Based on a Relicensure Survey completed on June 4, 2024, it was determined that The Center for Same Day Surgery was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a four story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.







Plan of Correction:




28 Pa. Code 569.2 STANDARD
Vertical Openings - Enclosure

Name - MAIN BUILDING 01 Component - 01
Vertical Openings - Enclosure
2012 EXISTING
Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Unenclosed openings which do not serve as a required means of egress are permitted.
3. Exit access stairs may be unenclosed if they meet the following conditions:
Two stories or less
a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1).
b. Total travel distance to outside does not exceed 100 feet.
Three stories or less
a. Occupant load per story does not exceed 15 people.
b. Building is sprinkler protected throughout per 9.7.1.1(1).
c. Building contains an automatic smoke detection system per 9.6.
d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building.
e. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2

Observations:

Based on observation and interview, it was determined the facility failed to maintain vertical openings in one location, affecting four of four floors.

Findings include:

1. Observation on June 4, 2024, at 11:11 a.m., revealed the following items were located within the stair tower one enclosure, located at the penthouse level:

a. newspaper.
b. chair.
c. five gallon can of oil.

Exit interview with the Facilities Manager on June 4, 2024, at 12:45 p.m., confirmed the vertical opening deficiency.





Plan of Correction:

The items in the stair tower were removed upon discovery, in the presence of the surveyor. This included the newspaper, chair and the five gallon can of oil.
All areas of all stairwells in the building were inspected and found to be compliant.
Staff were instructed not to leave items in the stairwell on June 4, 2024 at 3:45pm.
Quarterly inspections will be completed to ensure the stairwells are kept sterile of obstructions in the means of egress.
Results of these inspections will be reported to the Environment of Care Committee on a quarterly basis.