QA Investigation Results

Pennsylvania Department of Health
BRYN MAWR MEDICAL SPECIALIST ENDOSCOPY ASSOCIATES LTD.
Building Inspection Results

BRYN MAWR MEDICAL SPECIALIST ENDOSCOPY ASSOCIATES LTD.
Building Inspection Results For:


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Initial Comments:
Name - RELOCATED CLASS B ASF Component - 10

Facility ID# 17101501
Component 10
Medical Arts Pavilion

Based on a Relicensure Survey completed on April 14, 2021, it was determined Bryn Mawr Medical Specialist Endoscopy Associates Ltd, was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Health Care Occupancy.

This is a four story, Type II (000), unprotected non-combustible construction, which is fully sprinklered.

Approved as a Class B Ambulatory Surgical Facility.






Plan of Correction:




28 Pa. Code 569.2 STANDARD
Multiple Occupancies

Name - RELOCATED CLASS B ASF 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 tenant separation walls, affecting one of four levels within the facility.

Findings include:

1. Observation on April 14, 2021, at 10:20 a.m., revealed on Level 3, inside the waiting room, above the suspended ceiling, there was an open conduit end, in the tenant separation wall.

Exit Interview with the Director of Nursing, Chief Executive Officer and Building Maintenance Representative on April 14, 2021, at 11:25 a.m., confirmed there was an open conduit end in the tenant separation wall.






Plan of Correction:

Referring to 3M through penetration system# W-L-3347, The open ended conduit has been sealed using 3M CP 25WB+ (Fire Rated up to 4 hours) caulk in accordance with UL 1479 and 3M system# W-L-3347.

Measures we will take to ensure the problem does not recur:

The building engineer or designee will be contacted to perform visual inspection of the tenant separation walls on a semi-annual basis, reporting all findings to the Administrative Director.

The Administrative Director will instruct all contractors, vendors and employees to seal any penetrations when performing work on the tenant separation walls. All areas will be inspected by the building engineer upon completion.


28 Pa. Code 569.2 STANDARD
Emergency Lighting

Name - RELOCATED CLASS B ASF Component - 10
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9

Observations:

Based on observation and interview, it was determined the facility failed to maintain emergency battery back-up lighting, affecting one of four levels within the facility.

Findings include:

1. Observation on April 14, 2021, at 11:00 a.m., revealed, on Level 1, inside the main electrical switch room, the emergency battery back-up light did not function when tested.

Exit Interview with the Director of Nursing, Chief Executive Officer and Building Maintenance Representative on April 14, 2021, at 11:25 a.m., confirmed the battery back-up light did not function when tested.






Plan of Correction:

The battery in the emergency back-up lighting located in the main electrical switch room has been replaced and tested to ensure it is in working order.

Measures we will take to ensure the problem does not recur:

1) The building engineer will perform monthly checks on all emergency lighting in and around the building outside of the ASC and report any repairs or maintenance required to the Administrative Director. A record will be kept of the monthly checks to ensure compliance.


28 Pa. Code 569.2 STANDARD
Vertical Openings - Enclosure

Name - RELOCATED CLASS B ASF Component - 10
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 the fire resistive rating of vertical openings, affecting one of four levels within the facility.

Findings include:

1. Observation on April 14, 2021, at 10:35 a.m., revealed, on Level 3, in the corridor, above the suspended ceiling, there was an approximately 2" x 3" unsealed square penetration, in the stair tower wall.

Exit Interview with the Director of Nursing, Chief Executive Officer and Building Maintenance Representative on April 14, 2021, at 11:25 a.m., confirmed the unsealed penetration in the stair tower wall.






Plan of Correction:

The cutout in the stair tower wall will be resealed using Through Penetration Firestop System Number W-L-3148 in accordance with UL 1479 certified fire stop system for use in 1 and 2 hour rated firewalls.

Measures we will take to ensure the problem does not recur:

1. The building engineer or designee will be contacted to perform a visual inspection of the tenant separation walls on a semi-annual basis, reporting all findings to the Administrative Director.

2. The Administrative Director will instruct all contractors, vendors and employees to seal any penetrations using a through-penetration firestop system.