Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 22411501
Component 01
Based on a Relicensure Survey completed on December 19, 2023, it was determined that Trevose Specialty Care 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 two story, Type V (000), unprotected wood frame contruction, that is fully sprinklered
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Vertical Openings - Enclosure
Name - CLASS C 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 maintain the fire resistance of vertical openings, affecting the entire facility.
Findings include:
Observation on December 19, 2023, at 9:12 a.m., revealed open penetrations by data cables and other openings above the door to the rear stairwell.
Exit interview with the Administratir on December 19, 2023, at 9:30 a.m., confirmed the open penetrations and openings.
Plan of Correction:On December 19, 2023, the Life Safety surveyor revealed to the facility Administrator that they observed open penetrations from data cables above the dropped ceiling, above the door, leading to the rear stairwell.
Immediately after the completed survey, the Administrator spoke to the building repairman to address the need for the penetrations to be sealed with drywall and/or fire caulk. He verbalized understanding and assured the repair to be completed no later than January 31, 2024.
Moving forward, the facility Administrator addressed with facility personnel the need to communicate any future phone/data changes, replacements, and repairs. This will eliminate any wall penetrations made that will require observation of appropriate wall closure allowing protection from the openings. The findings of the survey were reported to the Medical Director and Board of Managers on 12-28-2023.
Any new changes to existing walls must be reported to the Patient Safety and Quality Assurance Committees as well as the Medical Advisory Board and Board of Managers on an on-going basis.
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