Initial Comments:
Name - WEST SHORE PAIN MANAGEMENT CENTER ASF Component - 01
Facility ID #23821501
Component 01
Surgery Center
Based on a Relicensure Survey completed on February 12, 2024, it was determined that UPMC Pinnacle Procedure Center was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a four-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Multiple Occupancies
Name - WEST SHORE PAIN MANAGEMENT CENTER 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 maintain the 1-hour fire resistance rating, at one of three communicating openings within the component.
Findings include:
1. Observation on February 12, 2024, at 12:00 PM, revealed the fire-rated door, separating the Practice from the Center, between the corridor and Reception Area, was being held open by wooden wedge.
Interview with the Facilities Director on February 12, 2024, at 12:00 PM, confirmed the door was being held open.
Plan of Correction:Door wedge was removed immediately, and door was closed. Wooden wedge was discarded.
Staff was educated on the importance of keeping door shut when not in use. This will be added to our annual education training. A sign has been ordered for the door that states "please keep closed" as a visual reminder to staff.
Daily audits will be done with 100% compliance that the door will be observed as closed when not in use. Education will be completed yearly with 100% compliance.
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