Initial Comments:
Name - ADVANCED CENTER FOR SURGERY LLC Component - 01
Facility ID# 23191501
Component 01
Main Building
Based on a Relicensure Survey completed on April 25, 2024, it was determined that Advanced Center for Surgery 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, without a basement, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - ADVANCED CENTER FOR SURGERY LLC 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 three instances, affecting one of two smoke compartments.
Findings include:
1. Observation on April 25, 2024, revealed the following automatic sprinkler system deficiencies:
a) 10:10 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the receiving area;
b) 10:12 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the material management office;
c) 10:30 a.m., there were multiple unsealed penetrations in the ceiling of the sterilizer access room.
Interview with the Facility Administrator and the Maintenance Director on April 25, 2024, at 11:30 a.m., confirmed the listed automatic sprinkler system deficiencies.
Plan of Correction:A.
1. To correct the 18-inch horizontal sprinkler deficiency in the receiving area, we have removed all objects from the top shelves. The items were placed in a designated storage area. This occurred on 04/26/2024.
2. To ensure the facility maintains compliance, our maintenance/assistant clinical director will observe the items in the storage area on a weekly basis.
3. The appropriate clinical staff were educated on proper storage of items to ensure safety and compliance.
B.
1. To correct the 18-inch horizontal sprinkler deficiency in the materials managers office area, we have removed all objects from the top shelves. The items were placed in a designated storage area. This occurred on 04/26/2024.
2. To ensure the facility maintains compliance, our maintenance/assistant clinical director will observe the items in the materials managers office on a weekly basis.
3. The appropriate clinical staff were educated on proper storage of items to ensure safety and compliance.
C.
1. The maintenance/assistant clinical director has scheduled R.T. Contracting to seal the unsealed penetrations around the piping in the sterilizer access room. This work will be completed by 05/08/2024.
2. To ensure the surgery center is in compliance with Life Safety Code requirements for an existing Ambulatory health care facility, the maintenance/assistant clinical director will thoroughly examine the building on a weekly basis. Any items that fail to meet code, will be addressed and corrected within 30 days of findings.
28 Pa. Code § 569.2 STANDARD
Electrical Systems - Other
Name - ADVANCED CENTER FOR SURGERY LLC Component - 01
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Observations:
Based on observation and interview, it was determined the facility failed to maintain electrical wiring in one instance, affecting one of two smoke compartments. Installation shall be in accordance with NFPA 70, National Electric Code 19.5.1.1, and NFPA 101.
Findings include:
1. Observation on April 25, 2024, at 10:45 a.m., revealed there was an open electrical junction box on the wall of the boiler room above the water conditioner.
Interview with the Facility Administrator and the Maintenance Director on April 25, 2024, at 11:30 a.m., confirmed the listed electrical wiring deficiency.
Plan of Correction:1.The maintenance/assistant clinical director properly secured the electrical junction box on the wall of the boiler room above the water conditioner in accordance with NFPA 70, National Electric Code 19.5.1.1, and NFPA 101. This occurred on 04/26/2024.
2. The maintenance/assistant clinical director will examine all outside contracted projects to be in compliance with the Life Safety Code for existing Ambulatory health care facilities prior to the outside contractor leaving the facility upon project completion.
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