Initial Comments:
Name - CLASS C ASF, 1122 STREET RD, SOUTHAMPTON, PA 18966 Component - 10
Facility ID# 15931501
Component 10
Based on a Relicensure Survey completed on February 5, 2024, it was determined Kole Plastic Surgery Center, LLC was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.
This is a two-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.
Approved as a Class C Ambulatory Surgical Facility.
Plan of Correction:
NFPA 101 STANDARD
Multiple Occupancies
Name - CLASS C ASF, 1122 STREET RD, SOUTHAMPTON, PA 18966 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 tenant separation walls, affecting one location within the facility.
Findings include:
Observation on February 5, 2024, at 9:40 a.m., revealed, in the procedure room, an unsealed penetration around a PVC pipe.
Exit Interview with the Medical Director on February 5, 2024, at 10:00 a.m., confirmed the unsealed penetration.
Plan of Correction:The firewall above the ceiling on the left side of the procedure room was missing adequate fire caulk completely around a PVC pipe.
After being notified by the inspector of the deficiency, the missing fire caulk was replaced with an approved through stop penetrant around the entire separation between the PVC pipe and the firewall on February 6th 2024.
The maintenance contractor for the ASC performed a complete visual firewall inspection of the demarcation wall above the ceiling of the ASC and reinforced any fire caulk that appeared to be separated, incompletely adhered to, or had shrunk away from the penetration that it was intended to protect.
Photographs of the deficiency before repair, the materials used and the after-correction photos were sent to the inspector on February 19th, 2024 by email.
We will continue to monitor for ongoing caulk shrinkage along the demarcation wall of the ASC when performing our monthly penetration inspection of the Facility. The facility will maintain the separation between the ASC and the other spaces in the building as per Life Safety code.
This fire caulk's visual inspection will be added to the ASC's Facility Inspection Logbook. The completed repair of the fire caulk is available for immediate inspection if the Inspector requests it.
The reports will be reviewed and Audited by the Patient Safety Committee and recorded at the Patient Safety Committee meeting and reported to the Governing Body.
NFPA 101 STANDARD
Gas and Vacuum Piped Systems - Maintenance
Name - CLASS C ASF, 1122 STREET RD, SOUTHAMPTON, PA 18966 Component - 10
Gas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
Observations:
Based on document review and interview, it was determined the facility failed to maintain the medical gas system, affecting one medical gas system.
Findings include:
Document review on February 5, 2024, at 9:00 a.m., revealed, the complete medical gas report for the current year was not available for review at the time of survey.
Exit Interview with the Medical Director on February 5, 2024, at 10:00 a.m., confirmed the missing documentation.
Plan of Correction:
The Medical Gas System was inspected in its entirety on February 9, 2024 by an approved Medical Gas Contractor. The entire report was notarized on February 12, 2024.
The Medical gas outlets, medical gas inlets, area alarms, master alarms, zone valves, oxygen and vacuum systems all passed inspection as per NFPA 99 2012 (5.1.14.2.2 thru 5.1.15).
The medical gas and vacuum data sheets for the Operating Room and Recovery Room beds as well as the Alarm data sheets, zone valve box data sheets, manifold data sheets and vacuum pump inspection report were included in the documents.
Although the Medical gas system and vacuum system passed inspection, the medical gas company was contracted to also perform a 6 month preventative maintenance check on all equipment moving forward.
The Complete Annual Gas inspection report was emailed to the inspector on February 28th 2024 and will be available in hard copy for review if the Inspector requests.
The future Preventative maintenance reports will also be kept in the Medical Gas Inspection file for future Inspector review.
The recommendations of the medical gas contractor will be followed and documented if any repairs are to be performed or recommended.
Any deficiencies in the gas system and vacuum system will be reported to the medical director to be remedied. The ASC will not operate if any medical gas inspection report states there is a danger in any way to patient safety.
|