Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 23671501
Component 01
Based on a Relicensure Survey completed on September 16, 2020, it was determined Einstein Medical Center Montgomery Short Procedure Unit was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Health Care Occupancy.
This is a two-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.
Approved as a Class C Ambulatory Surgical Facility.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - CLASS C ASF Component - 01
Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44
Observations:
Based on observation and interview, it was determined the facility failed to ensure tenant separations maintained a fire resistance rating, affecting one of several occupancies within this facility.
Findings include:
1. Observation on September 16, 2020, at 9:40 a.m., revealed the door frame of the Pre/Post exit door was missing its fire rating tag.
Exit interview with the Director of Quality on September 16, 2020, at 11:30 a.m., confirmed the missing fire rating tag.
Plan of Correction:Barrier Compliance Services, a Life Safety testing company, has been contacted to inspect the above noted door frame and install the appropriate fire rated sticker.
In the future, the Director of Facilities or designee, will inspect all fire rated doors quarterly to ensure that all required stickers are in place.
Completion Date
10/31/2020
28 Pa. Code § 569.2 STANDARD
Vertical Openings - Enclosure
Name - CLASS 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, it was determined the facility failed to ensure vertical openings between floors maintained a fire resistance rating, affecting one of two levels within the facility.
Findings include:
1. Observation on September 16, 2020, at 10:40 a.m., revealed an open penetration in the ceiling deck of the Communications Room by a Sanitary pipe.
Exit interview with the Director of Quality on September 16, 2020, at 11:30 a.m., confirmed the vertical opening.
Plan of Correction:The noted penetration will be sealed using high-performance intumescent fire stop sealant - Hilti FS-One #2101531. In addition, the following approved through penetration fire stop system will be used in the location and is kept on file by the Director of Facilities: Hilti System No. C-AJ-8044
In the future, when ceiling work is completed, the Director of Facilities or designee will inspect the areas for new penetrations and will have them sealed immediately.
Completion Date
10/31/2020
28 Pa. Code § 569.2 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 properly maintain the sprinkler system, affecting one of two smoke compartments.
Findings include:
1. Observation on September 16, 2020, at 10:00 a.m., revealed data wires laying on the sprinkler pipe above the ceiling of the Staff Lounge.
Exit interview with the Director of Quality on September 16, 2020, at 11:30 a.m., confirmed the data wire laying on the sprinkler pipe.
Plan of Correction:The data wires in question have been relocated to ensure that they are not laying on the sprinkler pipe.
In the future, when ceiling work is completed, the Director of Facilities or designee, will inspect the areas to ensure that the sprinkler system is not compromised in any way. Any deficiencies will be corrected immediately.
Completion Date
09/19/2020
28 Pa. Code § 569.2 STANDARD
Utilities - Gas and Electric
Name - CLASS C ASF Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2
Observations:
Based on observation and interview, it was determined the facility failed to electrical wiring was maintained in accordance with NFPA 70, National Electric Code, affecting one of two smoke compartments within the facility.
Findings Include:
1. Observation on September 16, 2020, revealed an unsecured junction box above the ceiling in the staff lounge.
Exit interview with the Director of Quality on September 16, 2020 at 11:30 a.m., confirmed the unsecured junction box.
Plan of Correction:The junction box in question has been secured in accordance with National Electrical Code.
In the future, when ceiling work is completed, the Director of Facilities or designee, will inspect the areas to ensure that there are no unsecured electrical boxes. Any deficiencies will be corrected immediately.
Completion Date
09/19/2020
28 Pa. Code § 569.2 STANDARD
HVAC
Name - CLASS 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 required inspections for Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting one of two smoke compartments the facility.
Findings include:
1. Document review on September 16, 2020, between 8:15 a.m. and 9:30 a.m., revealed the facility was missing documentation fire/smoke dampers had been tested within the past four years.
Exit interview with the Director of Quality on September 16, 2020 at 11:30 a.m., confirmed the missing documentation for the damper testing.
Plan of Correction:The Property Manager has been contacted to schedule the above noted fire/smoke dampers inspection. Moving forward, a schedule will be established by the Director of Project Management and Real Estate, along with the Property Manager, indicating the deadline for the completion of the every 4-year inspection. The deadline will be established no more than 2 weeks prior to the anniversary of the last inspection date.
Completion Date:
10/31/2020
28 Pa. Code § 569.2 STANDARD
Gas and Vacuum Piped Systems - Signs
Name - CLASS C ASF Component - 01
Gas and Vacuum Piped Systems - Information and Warning Signs
Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency.
5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to properly label the piped-in medical gas piping, affecting one of two smoke compartments of the facility.
Findings include:
1. Observation on September 16, 2020, revealed directional labels on the Medical Vacuum and Oxygen inside the Clean Corridor outside OR 4 were reversed from the direction the gas/vacuum was flowing.
Exit interview with the Director of Quality on September 16, 2020, at 11:30 a.m., confirmed the reversed medical gas piping labels.
Plan of Correction:The facility medical gas vendor will be scheduled to inspect and evaluate the medical gas labeling. All necessary corrections will be made at that time.
In the future, when above ceiling work is completed, the Director of Facilities or designee, will verify that the medical gas labeling has not been altered in any way. Any deficiencies will be corrected immediately.
Completion Date:
10/31/2020
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - CLASS C ASF Component - 01
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Based on document review and interview, it was determined the facility failed to maintain required testing of the emergency generator, affecting the entire building.
Findings include:
1. Document review on September 16, 2020, between 8:15 a.m. and 9:30 a.m., revealed the facility was missing the following documentation for the maintenance and testing of the emergency generator:
a. Annual load bank test;
b. Weekly voltage test of the batteries;
c. Monthly battery conductance test.
Exit interview with the Director of Quality on September 16, 2020, at 11:30 a.m., confirmed the missing documentation for the maintenance and testing of the emergency generator.
Plan of Correction:The required annual load bank test was completed on 09/20/2020.
Weekly voltage testing of batteries will continue per NFPA guidelines.
Monthly battery conductance testing will begin October 22, 2020 per NFPA Guidelines.
Moving forward, the Director of Facilities will ensure that the above tests are being completed, as required, via random log audits.
Completion Date:
10/23/2020
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