Initial Comments:
Name - ASF Component - 01
Facility ID# 20911501
Component 01
Main Building
Based on a Relicensure Survey completed on March 21, 2024, it was determined that Laurel Laser and Surgery Center-Altoona was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a one-story, Type II (000), unprotected noncombustible building, with a basement and mezzanine, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
General Requirements - Other
Name - ASF Component - 01
General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.
Observations:
Based on documentation review and interview, it was determined the facility failed to perform the required annual fire-rated door assembly inspection, affecting the entire facility. In accordance with NFPA 80 (2010 Edition) 5.2.1.
Findings include:
1. Observation and documentation review on March 21, 2024, at 9:30 a.m., revealed the facility failed to perform the required annual fire-rated door assembly inspection in the past 12 months. The most recent testing was performed on February 12, 2023.
Interview with the Facility Administrator on March 21, 2024, at 11:45 a.m., confirmed the listed fire-rated door assembly inspection deficiency.
Plan of Correction:Fire door testing was completed March 30, 2024 by building maintenance, and will be added to the yearly maintenance tickler list for Building Maintenance.
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - ASF 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 a one-hour fire-resistance rating to separate the health care occupancy from other occupancies in one instance, affecting the entire facility.
Findings include:
1. Observation on March 21, 2024, at 10:50 a.m., revealed the one-hour fire-resistive occupancy separation double doors in the waiting room failed to self-close and latch in their frame when tested.
Interview with the Facility Administrator on March 21, 2024, at 11:45 a.m., confirmed the listed one-hour fire-resistive occupancy separation deficiency.
Plan of Correction:Building contractor scheduled for Thursday, April 11th 2024 to repair door closure to ensure proper functioning. Door closures to be added to monthly test checklists for building maintenance team.
28 Pa. Code § 569.2 STANDARD
Emergency Lighting
Name - 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 documentation review, observation, and interview, it was determined the facility failed to maintain emergency lighting in one instance, affecting the entire facility.
Findings Include:
1. Observation and documentation review on March 21, 2024, at 9:30 a.m., revealed the facility failed to perform an annual 90-minute test of the battery backup lighting in the past 12 months. The most recent testing was performed on February 28, 2023.
Interview with the Facility Administrator on March 21, 2024, at 11:45 a.m., confirmed the listed emergency lighting inspection deficiency.
Plan of Correction:90 minute emergency lighting test was performed by building maintenance on 3/30/2024, and was added to the maintenance tickler list for January of all subsequent years.
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