Initial Comments:
Name - ASC Component - 01
Facility ID# 17611501
Component 01
Main Building
Based on a Relicensure Survey completed on September 6, 2023, it was determined that 20/20 Surgery Center, LLC was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 28 Pa Code 569.2.
This is a one-story, Type II (000), unprotected noncombustible building, with a basement, that is not sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Means of Egress - General
Name - ASC Component - 01
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1
Observations:
Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.
Findings include:
1. Review of documentation on September 6, 2023 at 8:30 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection.
Interview with the Facility Administrator on September 6, 2023, at 8:30 a.m. confirmed the annual fire door assembly inspection documentation was not available at the time of survey.
Plan of Correction:The Administrator reviewed the door inspection and that they needed to be completed annually.
The Administrator and Director of Nursing will sign off that the door inspections are completed annually.
POC will be initiated immediately and compliance will be on going.
The Administrator will only accept 100% compliance and will continue to monitor.
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