Initial Comments:
Name - CLASS B & C ASF Component - 01
Facility ID# 23291501
Component 01
Based on a Relicensure Survey completed on September 13, 2023, it was determined Philadelphia Surgery Center, Inc., 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 construction, with a basement, which is fully sprinklered.
Approved as a Class B & C Ambulatory Surgical Facility.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Vertical Openings - Enclosure
Name - CLASS B & C ASF Component - 01
Vertical Openings - Enclosure
2012 EXISTING
Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Unenclosed openings which do not serve as a required means of egress are permitted.
3. Exit access stairs may be unenclosed if they meet the following conditions:
Two stories or less
a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1).
b. Total travel distance to outside does not exceed 100 feet.
Three stories or less
a. Occupant load per story does not exceed 15 people.
b. Building is sprinkler protected throughout per 9.7.1.1(1).
c. Building contains an automatic smoke detection system per 9.6.
d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building.
e. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2
Observations:
Based on observation and interview, the facility failed to maintain the fire resistance rating of vertical penetrations, affecting one of two levels.
Findings Include:
1. Observation on September 13, 2023, at 10:30 am, revealed, basement mechanical room had an unknown expanding foam product installed around existing penetrations.
Exit Interview with the Administrator and Director of Nursing on September 13, 2023, at 10:50 am, confirmed the unknown foam substance.
Plan of Correction:Contractors have been contacted to remove the improperly installed expanding foam product from existing penetrations. The existing penetrations will then have approved and appropriate fire caulk installed. The work shall be completed no later than October 31, 2023. On a semi-annual basis, the administrator, director of nursing or designee will verify that there is no expanding foam product and that any penetrations will have appropriate fire caulk installed. Findings from these visual audits will be documented and reported to the Medical Advisory Board and Governing Body through the end of Quarter 4 2024.
28 Pa. Code § 569.2 STANDARD
HVAC
Name - CLASS B & C ASF Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting two of two levels.
Findings include:
1. Document review on September 13, 2023, at 9:40 am, revealed the facility lacked documentation that a four-year inspection of the fire/smoke dampers was performed. (HVAC drawing indicated fire/smoke damper at floor penetration).
Exit Interview with the Administrator and Director of Nursing on September 13, 2023, at 10:50 am, confirmed damper inspection documentation was not available.
Plan of Correction:Mechanical Contractor at the facility on September 14, 2023 and located a manual fire/smoke damper in the HVAC ducts. The director of nursing was informed that the damper is open and functioning. On an annual basis, through the end of Quarter 4, 2027, the administrator, director of nursing or designee will verify that appropriate inspection documentation is available and that inspection has occurred within the appropriate 4-year interval. Findings from this annual visual audit will be reported to the Medical Advisory Board and Governing Body at their respective meetings.
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