Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 17411501
Component 01
Main Building
Based on a Relicensure Survey completed on December 8, 2023, it was determined Philadelphia Institute Of Cosmetic Surgery was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This a two-story, Type II (222), fire resistive construction, with a lower level, which is partially sprinklered. The building is sprinklered in exit passageways and stairtowers only.
Approved as a Class C Ambulatory Surgical Center.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Emergency Lighting
Name - CLASS C ASF Component - 01
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, document review and interview, it was determined the facility failed to maintain required testing of back-up emergency lighting, affecting one of one location.
Findings Include:
1. Observation and documentation reviewed on December 8, 2023, at 10:30 a.m., revealed monthly 30-second testing of emergency back-up lighting inside the generator transfer switch room was not available for review.
Exit Interview with the facility Maintenance Director on December 8, 2023, at 11:00 a.m., confirmed testing of emergency lighting was incomplete.
Plan of Correction:Fire and Safety Policy 301 has been updated to reflect the requirements for a monthly 30 second testing of emergency back-up lighting inside the generator transfer switch.
The policy states a monthly 30 second testing of emergency back-up lighting inside the generator transfer switch will be conducted by the Assistant Administrator. If event occurs the Assistant Administrator must submit a report to QA and Patient Safety committee.
Administrator conducted an in-service education on the updated Fire & safety Policy 301 on 1/08/24.
Governing Board, QA committee, and Patient Safety committee, will ensure compliance of expectancy of 100% benchmark.
|