QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - CLASS B ASF Component - 01

Facility ID# 23111501
Component 01
Main Building

Based on a Relicensure Survey completed on August 29, 2022, it was determined Azura Vascular Care South 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 nonsprinklered.

Plan of Correction:

28 Pa. Code 569.2 LICENSURE
Fire Safety Standards

Name - CLASS B ASF Component - 01
(a) An ASF shall meet the applicable edition of National Fire Protection Association 101 Life Safety Code, which is currently adopted by the Department.

(b) An ASF previously in compliance with prior editions of the Life Safety Code, is deemed in compliance with subsequent Life Safety Codes, except renovation or new construction shall meet the current edition adopted by the Department.

Hazardous areas separated from other parts of the building by fire barriers have at least one hour fire resistance rating or such areas are enclosed with partitions and doors and the area is provided with an automatic sprinkler system. High hazard areas are provided with both fire barriers and sprinkler systems 39.3.2


Based on observation and interview, it was determined the facility failed to maintain three hazardous area enclosures, affecting one of one floor.

Findings include:

1. Observation on August 29, 2022, between 2:12 p.m. and 2:20 p.m., revealed the following:

a. 2:12 p.m., Receiving Storage Room lacked one hour, fire resistive integrity beyond the suspended ceiling assembly, a forty-five minute rated door, and self-closing device.
b. 2:16 p.m., Soiled Utility Room door required adjustment to fully latch.
c. 2:20 p.m., Sterile Supplies Room door required adjustment to fully latch.

Exit interview with the Facility Administrator on August 29, 2022, at 2:40 p.m., confirmed the hazardous area enclosure deficiencies.

Plan of Correction:

Change: The Receiving Room will be for deliveries only, as indicated by the signage on the door, "Deliveries Only". As of Friday, 9/16, the room will not be used for storage. Staff will be educated on the proper use of the room; receiving, unpackaging, dissemination of supplies and removal of shipping boxes by the end of business daily. This education will be documented. The Soiled Utility Room door and Sterile Supply Room door will be repaired by 9/30/22 and will positively latch.
Quality: The Administrator/Safety Office will perform an environment/life safety assessment of each room for proper utilization as designated and for all rooms considered hazardous areas to ensure self-closing doors positively latch. This assessment will be done quarterly and reported to the Quality Committee/Performance Improvement Committee and brought forth to the Governing Body for the next six (6) months. The next Quality and Governing Body meeting will occur prior to October 31, 2022.