Initial Comments:
Name - AREA D Component - 01
Facility ID# 17691501
Component 01
Main Building
Based on a Relicensure Survey completed on October 18, 2022, it was determined that Allegheny Surgery Center LLC, was not in compliance with the following requirements of the Life Safety Code for a existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).
This is a one-story, Type II (000), unprotected non-combustible building, without basement, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - AREA D Component - 01
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 one hour fire rated occupancy separation walls, in one instance, affecting the entire facility.
Findings include:
1. Observation on October 18, 2022, at 10:52 a.m., an above ceiling inspection in the hallway, at the recovery room access door, revealed an unsealed MC cable penetration.
Interview with the Facility Administrator and Facility Staff on October 18, 2022, at 12:30 p.m., confirmed the one hour fire rated occupancy separation wall deficiency.
Plan of Correction:#0131
The unsealed MC cable penetration located in the hallway above the recovery room access door will be sealed with "Fire Block" caulking to restore the integrity of the one-hour fire rated occupancy separation wall. The corrective action will be completed by the Director of Mall Maintenance.
The Quality Improvement Committe will discuss @ the quarterly meeting, any work or requests for work above the ceiling that may disrupt the integrity of the fire wall. Requests must be approved before any work may ensue. QI will monitor for @ least the next 2 quarters.
Corrective action will be complete by 11/11/2022
28 Pa. Code § 569.2 STANDARD
Hazardous Areas - Enclosure
Name - AREA D 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 hazardous area enclosures in one instance, affecting the entire facility.
Findings include:
1. Observation on October 18, 2022, at 10:25 a.m., revealed there was a clean linen cart, blocking one of two exits from the number eight storage room.
Interview with the Facility Administrator and Facility Staff on October 18, 2022, at 12:30 p.m., confirmed the hazardous area enclosure deficiency.
Plan of Correction:#0321
The Linen Cart was removed from the door in the Storage Room.
The Door was then marked with the designation "NOT AN EXIT"
An In-Service was held with all staff members regarding; proper storage of the linen cart, keeping exit doors free of clutter, and appropriately identifying doors that are not emergency EXITS.
The Linen Cart was removed from the front of the door on 10/18/2022.
Staff Education was completed on 10/18/22 and an in-service was completed on 11/3/2022.
The Quality Improvement Committee will make routine checks to assure that the door remains unobstructed by a visual inspection when safety checks are done.
Compliance will be reported @ the next 2 quarterly meetings.
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - AREA D 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 four instances, affecting the entire facility.
Findings include:
1. Observation on October 18, 2022, revealed the following automatic sprinkler system deficiencies:
a) 10:47 a.m., an above ceiling inspection in the recovery area revealed wires zipped tied to the sprinkler pipes;
b) multiple cables laying on top of the sprinkler pipes;
c) fire alarm wire wrapped around a sprinkler pipe;
d) Mc cable laying on top of sprinkler pipes.
Interview with the Facility Administrator and Facility Staff on October 18, 2022, at 12:30 p.m., confirmed the automatic sprinkler system deficiencies.
Plan of Correction:#0353
The Mall Manager consulted with Adams Electric to devise a plan to correct the issues noted above the ceiling impacting the sprinkler system.
The entire space above the center was inspected and both parties have coordinated a plan to correct deficiencies.
a. The zip tie will be removed from the sprinkler pipe.
b. all cables that are laying on top of sprinkler pipes will be removed from the pipes so that they are not obstructed.
c. the fire alarm wire will be removed from the sprinkler pipe.
d. MC cable will be removed from atop of the sprinkler pipes.
The completion date for the above corrections is 12/31/2022.
The Mall Manager will review upon completion, all work with administrator.
Any future work requiring entry into the space above the ceiling will be approved by the administrator after formal request.
The Quality Improvement Committee will monitor and report any requests made at the next 2 quarterly QI meetings.
28 Pa. Code § 569.2 STANDARD
Gas Equipment -Cylinder and Container Storage
Name - AREA D Component - 01
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to maintain medical gas storage requirements in one instance, affecting the entire facility.
Findings include:
1. Observation on October 18, 2022, at 10:34 a.m., revealed there was an unsecured oxygen cylinder stored in oxygen tank room.
Interview with the Facility Administrator and Facility Staff on October 18, 2022, at 12:30 p.m., confirmed the medical gas storage deficiency.
Plan of Correction:#0923
The unsecured oxygen tank was immediately placed in the oxygen storage cart.
The correction was made on 10/18/2022.
A discussion was held with all staff on the same date and a formal in-service was held on 11/3/2022. Discussion points were safe oxygen storage, types of acceptable storage containers, full and empty storage, ventilation requirements, and separation of combustible materials from gases.
Routine checks will be made to assure that the deficiency does not re-occur during the routine safety checks.
Reporting will take place at the next 2 quarterly QI meetings.
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