Initial Comments:
Name - CLASS C AMBULATORY SURGICAL FACILITY Component - 01
Facility ID# 21531501
Component 01
Based on a Relicensure Survey completed on August 22, 2024, it was determined Best Impression Surgical Center, Llc, was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a six-story, Type II (111), protected noncombustible structure, which is fully sprinklered.
Approved as a Class C Ambulatory Surgical Center.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - CLASS C AMBULATORY SURGICAL FACILITY 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 tenant separation doors to be within the allowed gap margins, and to be repaired using an authorized accessory, for one of one smoke zone within the component.
Findings include:
1. Observation on August 22, 2024, at 11:30 AM, revealed the Main Entrance rated door had gaps greater than 1/8 inch.
Interview with the Director of Nursing on August 22, 2024, at 11:30 AM, confirmed the rated door exceeded the allowed gap margins.
2. Observation on August 22, 2024, at 12:15 PM, revealed the rated Supply Room door, which is in the tenant separation wall, had an unsealed penetration and a penetration filled with putty.
Interview with the Director of Nursing on August 22, 2024, at 12:15 PM, confirmed the tenant separation door fire rating was not maintained.
Plan of Correction:
1) The Director of Nursing has notified the ASC's contractor to install GAP90,9590 90 minute Fire Door Cap Solutions to main entrance to make sure there are no gaps greater than 1/8 inch.
2) The Director of Nursing has notified the ASC's contractor to install a new plain sliced red oak, AFD-60 solid mineral core 60-minute fire rated, bond to core interior architectural wood flush door, WDMA grade "A" book & running match faces.
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