QA Investigation Results

Pennsylvania Department of Health
BETHLEHEM ENDOSCOPY CENTER, L.L.C.
Building Inspection Results

BETHLEHEM ENDOSCOPY CENTER, L.L.C.
Building Inspection Results For:


There are  18 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - MAIN BUILDING Component - 01

Facility ID# 15601501
Component 01
Main Building

Based on a Relicensure Survey completed on June 9, 2021, it was determined that Bethlehem Endoscopy Center, LLC, was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is two 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 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 one vertical opening, affecting two of two floors.

Findings include:

1. Observation on June 9, 2021, at 10:03 a.m., revealed the second floor suite door, which opens into the rear stair tower enclosure, required adjustment to fully latch.

Exit interview with the facility administrator on June 9, 2021, between 10:50 a.m. and 11:00 a.m., confirmed the vertical opening deficiency.




Plan of Correction:

Action:
1. On 6/18/2021 Summit Management and Realty Company (building management company) adjusted the second floor suite door, which opens into the rear stair tower to fully latch.
2. Added the following to policy EC-01(A) Form-Monthly Facility Safety and OSHA Checklist on Item 9. Physical plant is maintained in good condition: "k) All Vertical openings will be enclosed or protected (door will be fully latched).

Monitor
The organization's Safety Officer will monitor the doors monthly on the Facility Safety and OSHA Checklist to ensure compliance. Any items needing repair will be immediately reported to the Center Manager who will contact Summit Management and Realty Company the building management company to complete timely repairs.

Responsible
The Safety Officer will report to the Center Manager as needed and to the QAPI Committee quarterly. The Center Manager/QAPI Coordinator will present a QAPI report quarterly to the Board of Managers.


28 Pa. Code 569.2 STANDARD
Hazardous Areas - Enclosure

Name - MAIN BUILDING Component - 01
Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7

Observations:

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of two floors.

Findings include:

1. Observation on June 9, 2021, at 10:33 a.m., revealed the temporary Soiled Linen Holding Room door lacked a self-closing device,

Exit interview with the facility administrator on June 9, 2021, between 10:50 a.m. and 11:00 a.m., confirmed the hazardous area enclosure deficiency.




Plan of Correction:

Actions:
1. On 6/10/2021 Summit Management and Realty (building management company)attached the self-closing device to the Soiled Linen Holding Room door. The door now closes and latches completely when opened.

2. Added the following to policy EC-01(A) Form-Monthly Facility Safety and OSHA Checklist on Item 12. Fire safety rules are in effect and followed at all times: "e)Fire and smoke wall doors are closed or on automatic closing system and are functioning properly).

Monitor
The organization's Safety Officer monitor all self-closing doors to ensure all doors are working properly and completely closing when opened. The audits will be completed monthly on the Facility Safety and OSHA Checklist audits to ensure compliance. Any items needing repair will be immediately reported to the Center Manager who will contact Summit Management and Realty the building management company to complete timely repairs.

Responsible
The Safety Officer will report to the Center Manager as needed and to the QAPI Committee quarterly. The Center Manager/QAPI Coordinator will present a QAPI report quarterly to the Board of Managers.


28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - MAIN BUILDING Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of two floors.

Findings include:

1. Observation on June 9, 2021, at 10:10 a.m., revealed BX wiring was attached to sprinkler piping within the second floor Oxygen Room.

Exit interview with the facility administrator on June 9, 2021, between 10:50 a.m. and 11:00 a.m., confirmed the automatic sprinkler system deficiency.




Plan of Correction:

Action:
3. On 6/18/2021 Summit Management and Realty Company (building management company) removed the BX wiring attached to sprinkler piping within the second floor Oxygen Room.

4. Added the following to policy EC-01(A) Form-Monthly Facility Safety and OSHA Checklist on Item 12. Fire safety rules are in effect and followed at all times: "f)Nothing is attached to sprinkler piping.

Monitor
The organization's Safety Officer will monitor the sprinkler piping to ensure nothing is attached to the piping. This will be documented monthly on the Facility Safety and OSHA Checklist to ensure compliance. Any items needing repair will be immediately reported to the Center Manager who will contact Summit Management and Realty Company the building management company or sprinkler company to complete timely repairs.

Responsible
The Safety Officer will report to the Center Manager as needed and to the QAPI Committee quarterly. The Center Manager/QAPI Coordinator will present a QAPI report quarterly to the Board of Managers.