QA Investigation Results

Pennsylvania Department of Health
BEST IMPRESSION SURGICAL CENTER, LLC
Building Inspection Results

BEST IMPRESSION SURGICAL CENTER, LLC
Building Inspection Results For:


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Initial Comments:
Name - CLASS C AMBULATORY SURGICAL FACILITY Component - 01

Facility ID# 21531501
Component 01


Based on a Relicensure Survey completed on September 13, 2022, 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 non-combustible construction, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Center.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Fire Alarm System - Testing and Maintenance

Name - CLASS C AMBULATORY SURGICAL FACILITY Component - 01
Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5

Observations:

Based on document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire facility.

Findings include:

1. Document review on September 13, 2022, at 8:15 a.m., revealed the facility could not produce documentation of the following tests and inspections:

a. Semi-annual fire alarm inspection within 6 months prior to June 2, 2022;
b. Smoke detector sensitivity testing within the past 48 months.

Exit Interview with the Director of Nursing on September 13, 2022, at 10:00 a.m., confirmed the lack of documentation.





Plan of Correction:

DON has scheduled Oliver Sprinkler to do semi-annual fire alarm inspection with the smoke detector sensitivity testing. Facility will continue to do semi-annual every 6 months along with their quarterly inspection.
All work will be complete by 12/9/2022


28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - CLASS C AMBULATORY SURGICAL FACILITY 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 document review and interview, it was determined the facility did not maintain and inspect the sprinkler system, affecting the entire facility.

Findings include:

1. Document review on September 13, 2022, at 8:15 a.m., revealed the facility could not produce documentation of the following inspections:

a. Five year Internal valve inspection;
b. Five year Internal pipe inspection.

Exit Interview with the Director of Nursing on September 13, 2022, at 10:00 a.m., confirmed the lack of documentation.





Plan of Correction:

The DON has notified the Building Manager that the inspection on 9/13/2022 showed that the facility did not maintain and inspect the sprinkler system, affecting the entire facility.

1.) The building will get an Internal valve inspection that is good for 5 years.

2.) The building will get Internal pipe inspection good for 5 years.

All work will be completed by 12/9/2022
The DON will keep all records on file in the ASC.


28 Pa. Code 569.2 STANDARD
Subdivision of Building - Smoke Barrier

Name - CLASS C AMBULATORY SURGICAL FACILITY Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5

Observations:

Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of smoke barrier walls, affecting one of two smoke compartments in the component.

Findings include:

1. Observation on September 13, 2022, at 9:50 a.m., revealed an open penetration, smoke barrier wall, above the ceiling, Anesthesia Workroom, by a data cable.

Exit Interview with the Director of Nursing on September 13, 2022, at 10:00 a.m., confirmed the open penetration.





Plan of Correction:

The DON has contacted the Center's contractor to make repairs to the open penetration above the ceiling in the Anesthesia work room, by the data cable.

A-Through penetration fire stop system will be used C-AJ-2001.3M fire barrier sealant CP25WB to seal all penetrations.

The DON will make sure all work is completed by 12/9/22.