Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 22871501
Component 01
Main Building
Based on a Relicensure Survey completed on March 07, 2024, it was determined that Penn State Hershey Endoscopy 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 one story, Type II (000), unprotected, noncombustible building, that is fully sprinklered
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Doors with Self-Closing Devices
Name - MAIN BUILDING 01 Component - 01
Doors with Self-Closing Devices
Doors required to be self-closing are permitted to be held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment, entire facility, and all stair enclosure doors upon activation of:
* Required manual fire alarm system, and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power
20.2.2.4, 20.2.2.5, 21.2.2.4, 21.2.2.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices, affecting one of one floors.
Findings include:
1. Observation on March 07, 2024 at 10:48 a.m., revealed the door, leading to the mechanical platform, was being held open with squeegee broom.
Interview at the time of the exit conference with the Administrator on March 07, 2024, between 11:00 a.m. and 11:15 a.m., confirmed the door was held open by unapproved means.
Plan of Correction:PROPERTY MANAGEMENT COMPANY WAS RE-EDUCATED RELATED TO PROPPING OF DOORS. THEY WILL EDUCATE VENDORS WHO ARE ONSITE THAT DOORS ARE NOT TO BE PROPPED OPEN. SQUEEGEE BROOM WAS REMOVED DAY OF SURVEY. NURSE MANAGER WILL DO A WALK THROUGH WEEKLY TO ENSURE NO DOORS ARE BEING PROPPED OPEN AND DOCUMENT RESULTS FOR A PERIOD OF 30 DAYS IF 100% COMPLIANCE IS ACHIEVED. IF DOORS ARE FOUND PROPPED OPEN DURING 30 DAY PERIOD THE WEEKLY WALK THROUGHS WILL CONTINUE FOR 60 DAYS WITH DOCUMENTATION TO ENSURE COMPLIANCE WITH STANDARD.
28 Pa. Code § 569.2 STANDARD
Exit Signage
Name - MAIN BUILDING 01 Component - 01
Exit Signage
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
20.2.10, 21.2.10, 7.10
Observations:
Based on observation and interview, it was determined the facility failed to ensure that doors that are neither an exit, nor a way of exit access, which could be mistaken for an exit, are clearly marked with appropriate signage, affecting one of one floors.
Findings include:
Observation on March 07, 2024, at 10:49 a.m, revealed the door leading to the rear exterior of the building, inside the mechanical room, lacked appropriate "NOT AN EXIT" signage. This door could be mistaken as an exit.
Interview at the time of the exit conference with the Administrator on March 07, 2024, between 11:00 a.m. and 11:15 a.m., confirmed the lack of signage.
Plan of Correction:DOOR WAS MARKED WITH A NO EXIT SIGN DAY OF SURVEY. DOOR WILL BE REPLACED WITH AN OPERATIONAL DOOR IN 4-6 WEEKS.
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