Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 14761501
Component 01
Main Building
Based on a Relicensure Survey completed on May 6, 2025, it was determined that Angelina Theresa Bucci Eye 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 two story, Type V (111), protected, wood frame building, that is nonsprinklered.
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 that the facility was not maintaining the proper fire resistance rating of the required tenant separation, on one of two floors.
Findings include:
1. Observation on May 6, 2025, at 10:04 a.m., revealed the rear emergency exit door leading to the exit enclosure, failed to positively latch into corresponding frame when tested.
Exit interview with Administrator on May 6, 2025, at 10:15 a.m., confirmed that the door failed to latch.
Plan of Correction:Administrator contacted building maintenance 5-6-25. Maintenance repaired latch on door 5-6-25. Implemented monthly check and log for all doors to ensure proper function. Monthly checks will begin 5-7-25. Administrator will monitor log completion each month.
28 Pa. Code § 569.2 STANDARD
Doors with Self-Closing Devices
Name - MAIN BUILDING 01 Component - 01
Doors with Self-Closing Devices
Doors required to be self-closing are permitted to be held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment, entire facility, and all stair enclosure doors upon activation of:
* Required manual fire alarm system, and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power
20.2.2.4, 20.2.2.5, 21.2.2.4, 21.2.2.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices, on one of two floors.
Findings include:
1. Observation on May 6, 2025, at 10:01 a.m., revealed the OR #2 door failed to positively latch into corresponding frame when tested.
Exit interview with Administrator on May 6, 2025, at 10:15 a.m., confirmed that the door failed to latch.
Plan of Correction:Administrator contacted building maintenance 5-6-25. Maintenance repaired latch on door 5-6-25. Implemented monthly check and log for all doors to ensure proper function. Monthly checks will begin 5-7-25. Administrator will monitor log completion each month.
28 Pa. Code § 569.2 STANDARD
Illumination of Means of Egress
Name - MAIN BUILDING 01 Component - 01
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
20.2.8, 21.2.8, 7.8
Observations:
Based on observation and interview, it was determined that illumination of means of egress was not maintained with the required illumination, on one of two floors.
Findings include:
1. Observation on May 6, 2025, at 9:55 a.m., revealed the exit sign above the door near medical records, was not illuminated.
Exit interview with Administrator on May 6, 2025, at 10:15 a.m., confirmed that the exit sign lacked illumination.
Plan of Correction:Contacted 3rd party emergency lighting/sign inspector (Cintas) 5-6-25 to correct deficiency from their recent annual visit on 4-25-25. Cintas returned 5-7-25 to inspect and repair emergency sign. Monthly emergency sign and lighting checks are already in place. Beginning 5-7-25 Administrator will accompany 3rd party inspectors to ensure proper completion. Administrator will document and verify work completed and documentation will accompany the report from 3rd parties and kept with the report.
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