QA Investigation Results

Pennsylvania Department of Health
AZURA VASCULAR CARE NORTHEAST PHILADELPHIA
Building Inspection Results

AZURA VASCULAR CARE NORTHEAST PHILADELPHIA
Building Inspection Results For:


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Initial Comments:
Name - CLASS C ASF Component - 01

Facility ID# 22641501
Component 01
Main Building

Based on a Relicensure Survey completed on September 9, 2024, it was determined that Azura Vascular Care Northeast Philadelphia, 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 III (200), unprotected, ordinary building, that is fully sprinklered.




Plan of Correction:




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

Name - CLASS C ASF Component - 01
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Smoke barrier doors shall be a minimum of 1-3/4 inches thick, solid-bonded wood core or equivalent with self-closing or automatic-closing devices in accordance with 21.2.2.4. Latching hardware is not required. Doors are not required to swing in the direction of egress travel.
21.3.7.9, 21.3.7.10

Observations:

Based on observation and interview, it was determined the facility failed to maintain two smoke barrier separation doors, affecting two of two smoke compartments.

Findings include:

1. Observation on September 9, 2024, between 2:28 p.m., and 2:36 p.m., revealed the following:

a. 2:28 p.m., the single, smoke barrier separation door, located at the Lobby entrance, exhibited a non-rated vision panel.
b. 2:36 p.m., the single, smoke barrier separation door, located in the Pre/Post-Op area, required adjustment to fully latch. The door was equipped with latchinig hardware.

Exit interview with the Facility Administrator on September 9, 2024, at 3:10 p.m., confirmed the smoke barrier separation door deficiencies.






Plan of Correction:

A.

1.Purchase and install a new fire rated door without a vision panel.

2. Install date 3/1/2025

3. No systemic changes will be required once doo is compliant.

4. Add new door details to the Fire and Smoke door inventory/testing form to be included in annual testing and inspection.

B.

1. Adjust the automatic-closing device on the door so that it positively latches when the door is ajar ninety degrees.

2. 9/12/2024

3. Educate staff that fire and smoke doors that have an automatic-closing device, must close and positively latch a hundred percent of the time.

4. continue with annual testing and inspection of fire and smoke rated doors.