QA Investigation Results

Pennsylvania Department of Health
DELMONT SURGERY CENTER, LLC
Building Inspection Results

DELMONT SURGERY CENTER, LLC
Building Inspection Results For:


There are  24 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on February 1, 2024, at Delmont Surgery Center it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




Plan of Correction:




Initial Comments:
Name - A0101 Component - 01


Facility ID# 22691501
Component 01
Main Building

Based on a Recertification/Relicensure Survey completed on February 1, 2024, it was determined that Delmont Surgery Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).

This is a two-story, Type V (000), unprotected wood frame building, without a basement, that is fully sprinklered.



Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Installation

Name - A0101 Component - 01
Fire Alarm - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
20.3.4.2.1, 21.3.4.1, 9.6

Observations:

Based on observation and interview, it was determined the facility failed to install the required automatic fire alarm system components in one instance, affecting the entire facility.

Findings include:

1. Observation on February 1, 2024, at 10:24 a.m., revealed there was no automatic smoke or heat detector on the first-floor at the main fire alarm control panel.

Interview with the Facility Administrator on February 1, 2024, at 11:30 a.m., confirmed the listed automatic fire alarm system deficiency.









Plan of Correction:

Nurse Administrator has reached out to Guardian Security System who monitors our fire alarms for the building to arrange for a smoke/heat detector to be installed on the first floor above the main fire alarm control panel to meet compliance.

Awaiting for Guardian Service department to return my call to arrange a date and time for this to be installed and to be added to our current monitoring service.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - A0101 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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting the entire facility.

Findings include:

1. Observation on February 1, 2024, revealed the following automatic sprinkler system deficiencies:

a) 10:15 a.m., revealed the facility failed to maintain a smoke/heat resistive ceiling for the proper activation/operation of the automatic sprinkler system. There were multiple unsealed penetrations in the first-floor mechanical room ceiling;
b) 10:21 a.m., the air compressor for the dry system located in the first-floor riser room was not anchored to the structure or fixed piping.

Interview with the Facility Administrator on February 1, 2024, at 11:30 a.m., confirmed the listed automatic sprinkler system deficiencies.



Plan of Correction:

Nurse Administrator has contacted Wright Maintenance (our maintenance company used for the building) and an in person walk through has been complete to identify areas of the ceiling tile that will need to be replaced as well as properly caulked to seal penetrations in the mechanical room ceiling.

Wright Maintenance will also anchor the air compressor for the dry system sprinkler appropriately to meet compliance.

This work is to be scheduled asap once Wright Maintenance informs me of days available for the work to be completed. Anticipated date of completion for all repairs is 3/1/24.