Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID #15301501
Main Building
Component 01
Based on a Relicensure Survey completed on March 21, 2024, it was determined that Reading Surgery Center of the Surgical Institute of Reading, 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 V (000), unprotected wood frame structure, without a basement, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
General Requirements - Other
Name - MAIN BUILDING 01 Component - 01
General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.
Observations:
28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.
35 P.S. 448.808. Issuance of license.
(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.
Based on observation and interview, it was determined the facility did not meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies, responsible for the health and welfare of residents within the component.
Findings include:
1. Observation on March 21, 2024, at 11:30 AM, revealed the facility failed to provide accurate and complete floor plans showing smoke barrier walls.
Interview with the Director of Facilities on March 21, 2024, at 11:30 AM, confirmed the plans provided were incorrect.
2. Observation and interview on March 21, 2024, at 11:30 AM, it was determined the facility had changed the use of the cubicle office area to a hazardous storage area without approved plans from the Department of Health.
Interview with the Director of Facilities on March 21, 2024, at 11:30 AM, confirmed plans were not submitted to plan review for the changes.
Plan of Correction:Corrective Action:
ASF Architect was contacted by the ASF Facilities Director on 4-3-24. A revised Life Safety drawing was received which reflects current use. The revised Life Safety drawing was sent to the Safety Inspector via email on 4-11-24. On the updated drawing, the cubicle area was updated to general equipment storage. This area was repurposed for general storage of equipment. The area is not designated to store hazardous material. The architect confirmed firewalls are correct on the updated Life Safety drawing.
DSI Central office was contacted on 4/22/24 and the procedure for review of change of use of space was been initiated. Plans and Life Safety Drawings for review will be electronically submitted on or before 4/27/24.
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