Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 21461501
Component 01
Building 01
Based on a Relicensure Survey completed on July 12, 2023, it was determined that Carbon Schuylkill Endoscopy Center 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 V (000), unprotected, wood frame building, with a basement, that is nonsprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Hazardous Areas - Enclosure
Name - MAIN BUILDING 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 location, affecting one of two floors.
Findings include:
1. Observation on July 12, 2023, ay 11:27 a.m., revealed a large quantity of storage items, located outside the hazardous area enclosures, located within the basement area.
Exit interview with the Facility Administrator at 11:55 a.m., on July 12, 2023, confirmed the hazardous area enclosure deficiency.
Plan of Correction:All materials outside of enclosure will be removed and will be placed in appropriate enclosed approved areas and or discarded. Date to be completed by is 8/5/2023.
Staff education on proper storage guidelines will be completed by 8/5/2023.
Further monitoring to prevent re- occurrence will be done weekly with walk through of basement area by DON or Administrator.
A log sheet will be added to document consistent monitoring of basement area to prevent re-occurrence of this issue.
All monitors are reported to QA committee for reveiw of compliance.
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