QA Investigation Results

Pennsylvania Department of Health
CLINICAL NEPHROLOGY ASSOCIATES, LTD.
Building Inspection Results

CLINICAL NEPHROLOGY ASSOCIATES, LTD.
Building Inspection Results For:


There are  15 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - CLASS B ASF Component - 01

Facility ID #22381501
Component 01
Ground Floor

Based on a Relicensure Survey completed on December 14, 2020, it was determined Clinical Nephrology Associates Ltd 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 non-combustible construction, which is fully sprinklered.

Approved as a Class B Ambulatory Surgical Facility.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Vertical Openings - Enclosure

Name - CLASS B ASF Component - 01
Vertical Openings - Enclosure
2012 EXISTING
Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Unenclosed openings which do not serve as a required means of egress are permitted.
3. Exit access stairs may be unenclosed if they meet the following conditions:
Two stories or less
a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1).
b. Total travel distance to outside does not exceed 100 feet.
Three stories or less
a. Occupant load per story does not exceed 15 people.
b. Building is sprinkler protected throughout per 9.7.1.1(1).
c. Building contains an automatic smoke detection system per 9.6.
d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building.
e. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2

Observations:

Based on observation and interview, it was determined the facility failed to ensure vertical openings between floors were sealed to maintain the fire resistance rating, affecting two of three floors within the facility.

Findings include:

1. Observation on December 14, 2020, at 9:55 a.m., revealed an unsealed penetration of the ceiling/floor assembly, by an approximately four inch sanitary line, above Treatment Bay 1 (left bay).

Interview at the exit conference with the Administrator on December 14, 2020, at 10:25 a.m., confirmed the unsealed penetration.





Plan of Correction:

The Facility will have the unsealed penetration of the ceiling/floor assembly, by an approximately four inch sanitary line, above Treatment Bay 1 (left bay) sealed with the appropriate smoke and fire penetration sealant by a certified fire proofing company using an approved through penetration fire stop system to seal the penetration through the floor assembly. This will be completed by January 15, 2021.


28 Pa. Code 569.2 STANDARD
Operating Features - Other

Name - CLASS B ASF Component - 01
Operating Features - Other
List in the REMARKS section any LSC Section 20.7 and 21.7 Operating Features requirements that are not addressed by the provided S-tags, but are deficient.

Observations:

Based on document review and interview, it was revealed the facility failed to maintain required policies in accordance with NFPA 101, 7.1.10.1, affecting the entire component.

Findings include:

1. Document review on December 14, 2020, between 8:15 a.m. and 9:35 a.m., revealed the facility was unable to provide a snow removal policy.

Interview at the exit conference with the Administrator on December 14, 2020, at 10:25 a.m., confirmed the lack of documentation.





Plan of Correction:

The Facility has since implemented a snow removal policy-
Policy Reference # 7065 has been approved and passed through the Governing Body.



28 Pa. Code 569.2 STANDARD
Fire Drills

Name - CLASS B ASF Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7

Observations:

Based on document review and interview, it was determined the facility failed to properly document required fire drills, affecting one of four fire drills.

Findings include:

1. Document review on December 14, 2020, between 8:15 a.m. and 9:35 a.m., revealed the fire drill for the First Quarter of 2020 did not list the times of the fire drill. Fire drills are required to be conducted once per shift per quarter.

Interview at the exit conference with the Administrator on December 14, 2020, at 10:25 a.m., confirmed the lack of proper documentation.







Plan of Correction:

The Center Manager has since re-educated Safety Designee of the importance of documenting time of drill on all fire drill reports. The Center Manager will review the next 2 quarters to ensure compliance of documenting time on reports.