Initial Comments:
Name - BERKS CENTER FOR DIGESTIVE HEALTH, LLC MAIN BUILDI Component - 10
Facility ID #15491501
Component 10
Main Building
Based on a Relicensure Survey completed on September 27, 2023, it was determined that Berks Center for Digestive Health, L.P. 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 II (000), unprotected noncombustible structure, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - BERKS CENTER FOR DIGESTIVE HEALTH, LLC MAIN BUILDI Component - 10
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 the facility failed to maintain the fire resistance rating of common walls to non-conforming buildings, affecting one of two smoke compartments within the component.
Findings include:
1. Observation on September 27, 2023, at 10:58 AM, revealed an unprotected penetration of the tenant separation wall, above the suspended ceiling, within the Clean Side Reprocessing Room, around a group of white wires.
Interview with the Administrator on September 27, 2023, at 10:58 AM, confirmed the unprotected penetration of the tenant separation wall.
2. Observation on September 27, 2023, at 11:25 AM, revealed an unprotected penetration of the tenant separation wall, above the suspended ceiling, within the Entryway Lobby, around a blue wire.
Interview with the Administrator on September 27, 2023, at 11:25 AM, confirmed the unprotected penetration of the tenant separation wall.
Plan of Correction:Citation: Berks Center for Digestive Health was cited for penetrations in the fire barrier. The penetrations were noted above the drop ceiling in the Scope Reprocessing room (Clean Side) and above the Main entry Door.
Immediate Action: The administrator completed a one-time tenant separation fire barrier audit on October 13, 2023. Audit results were reported to the Patient Safety Committee and Board of Managers on October 18, 2023. To sustain this PoC, the Quality Assurance committee created an "Above ceiling work system" process(tool). This system directs that all technicians performing construction, maintenance, or repairs must gain approval from the Administrator or Director of Nursing to penetrate the fire barrier. Once the construction, maintenance, or repairs are completed the Administrator or Director of Nursing (or designee) will inspect the area of penetration. Upon inspection the Administrator or Director of Nursing will confirm that the proper through penetration fire stop system was used, which will maintain the rating of the tenant separation. This system was reviewed by the Board of Managers. The fire barrier penetration was repaired using an approved through penetration fire stop system (NFPA-approved Fire Barrier Sealant).
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