Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on March 22, 2022, at Ambulatory Surgery Center At St Mary, Llc, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 22851501
Component 01
Based on a Recertification/Relicensure Survey completed on March 22, 2022, it was determined that Ambulatory Surgery Center At St. Mary, Llc, 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 four story, Type II (222), fire resistive construction, which is fully sprinklered.
Approved as a Class C Ambulatory Surgical Facility.
Plan of Correction:
NFPA 101 STANDARD
Interior Nonbearing Wall Construction
Name - CLASS C ASF Component - 01
Interior Non-bearing Wall Construction
Interior nonbearing walls in Type I or II construction are constructed of noncombustible or limited-combustible materials. Interior nonbearing walls required to have a minimum 2 hour fire resistance rating are permitted to be fire-retardant-treated wood enclosed within noncombustible or limited-combustible materials, provided they are not used as shaft enclosures.
21.1.6.3, 21.1.6.4
Observations:
Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating of an interior nonbearing wall, affecting two of two smoke compartments.
Findings include:
1. Observation on March 22, 2022, at 10:45 a.m., revealed an unsealed penetration between the rated drywall and corrugated decking, above the lay-in ceiling tile, located behind the recovery unit desk.
Exit Interview with the Executive Director, Director of Nursing, and Maintenance Representative on March 22, 2022, at 10:45 a.m., confirmed the unsealed penetration.
Plan of Correction:The penetration was sealed on 3/29/22 by St. Mary Plant Operations. The product used is Hilti High-Performance Intumescent Firestop Sealant FS-ONE MAX.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - CLASS C ASF 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 remain in compliance with sprinkler system requirements, for one of one sprinkler system.
Findings include:
1. Observation on March 22, 2022, at 11:23 a.m., revealed Sprinkler Room, bypass sprinkler valve had a damaged section of conduit between the junction box and valve.
Exit Interview with the Executive Director, Director of Nursing, and Maintenance Representative on March 22, 2022, at 11:23 a.m., confirmed the above section of conduit was damaged.
Plan of Correction:The damaged section of conduit/nipple connection between junction box and valve was replaced by St. Mary Plant Operations on 3/29/2022.
NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag
Name - CLASS C ASF Component - 01
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to maintain medical gas storage, in one of two smoke compartments.
Findings include:
1. Observation on March 22, 2022, at 10:56 a.m., revealed Storage, in the operating room corridor, had greater than 300 cubic feet of oxygen (over 12 e-sized cylinders) in storage.
Exit Interview with the Director of Nursing on March 22, 2022, at 10:56 a.m., confirmed the above storage room had greater than 300 cubic feet of oxygen at the time of the survey.
Plan of Correction:The facility re-evaluated oxgygen e-tank utilization and storage. Praxair was contacted to adjust par levels below threshhold of 300 cubic feet of O2. Less than 12 will be maintained on-site moving forward.
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