QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on October 29, 2020, at Allegheny Regional Endoscopy Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.

Plan of Correction:

Initial Comments:
Name - MAIN BUILDING Component - 01

Facility ID# 18631501
Component 01
Main Building

Based on a Recertification/Relicensure Survey completed on October 29, 2020, it was determined that Allegheny Regional Endoscopy Center 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 42 CFR 416.44(b).

This is a one-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered.

Plan of Correction:

Multiple Occupancies

Name - MAIN BUILDING 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.,,,,42 CFR 416.44

Based on observation and interview, it was determined the facility failed to provide a distinct waiting room for the ambulatory surgical center patients in accordance with 42 CFR 416.2, 42 CFR 416.44(b), and CMS Memorandum S&C-10-20-ASC, dated May 21, 2010.

Findings include:

1. Observation on October 29, 2020, at 10:00 a.m., revealed that the waiting room for surgical patients and visitors; was not separated from other entities and occupancy types by a one-hour fire rated tenant separation wall.

Interview with the Administrator and Maintenance Director on October 29, 2020, at 10:00 a.m., confirmed the above waiting area condition exists.

Plan of Correction:

Allegheny Regional Endoscopy assures that fire protection for the waiting area is appropriate for the occupancy to which it was designed. The ASCs waiting area is completely separated from the waiting area for the physicians practice by a temporary partition which does not block or obstruct visibility of exits, is flame resistant in accordance with NFPA 701, and is located at least 18 inches below sprinkler deflectors in accordance with NFPA 13. Additionally, signage is posted that clearly identifies the appropriate waiting area for the ASC versus the physician practice. Waiver request for separation of waiting areas submitted (mailed) to Mark Trocchio and Charles on 10-30-2020