Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 20221501
Component 01
Main Building
The ASC is located on the first floor
Based on a Relicensure Survey completed on September 13, 2023, at Western PA Surgery Center, Wexford Branch, LLC, was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a three-story, Type II (000), unprotected noncombustible building, without a basement, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING 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 2 instances, affecting the entire facility.
Findings include:
1. Observation on September 13, 2023, revealed the following automatic sprinkler system deficiencies:
a) 9:58 a.m., an above ceiling inspection in the OR corridor between OR #2 and OR #3 reveled there were wires zip tired to the sprinkler line;
b) 10:30 a.m., there was a gap greater than 1/8" in closet #139 in Pre-Op.
Interview with the Facility Staff on September 13, 2023, at 1:00 p.m., confirmed the above listed automatic sprinkler system deficiencies.
Plan of Correction:The facility maintenance has inspected and corrected all areas that were noted and any other visual ones so that the wires are not zip tied to any sprinkler system. Worked was completed on 9/22/2023. Gap in closet #139 in pre-op was corrected to close the 1/8 inch gap on 9/22/2023 by facility Maintenance.
In the future, Facility Maintenance will do checks of the sprinkler system as work is done in the ceiling to insure that no wires are attached to sprinkler system and yearly checks for entire Center. He has added this correction plan to his Facility Sprinkler/Fire check list.
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