Initial Comments:
Name - 6976 SQ FT FITOUT IN A 8978 SQ FT MOB Component - 01
Facility ID# 24301501
Component 01
Based on a Relicensure Survey completed on October 5, 2023, at The Pennsylvania Surgery And Laser Center, it was determined there were deficiencies identified under the requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a one-story, Type V (000), unprotected wood frame construction, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
General Requirements - Other
Name - 6976 SQ FT FITOUT IN A 8978 SQ FT MOB Component - 01
General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.
Observations:
Based on document review and interview, it was determined the facility failed to provide a set of accurate portable life safety floor plans. The Division of Safety Inspection requires that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey, affecting the entire facility.
Findings include:
1. Document review on October 5, 2023, at 8:30 am, revealed the facility could not provide a set of accurate portable life safety floor plans.
The Life Safety Code Floor Plans shall include the following:
a. Smoke Barrier Walls;
b. Fire Barrier Walls;
c. Horizontal Exits;
d. Hazardous Areas;
e. Required Exits should be clearly noted; and
f. Shafts Walls
Exit interview with the Administrator and the Maintenance Director on October 5, 2023, at 10:45 am, confirmed the lack of floor plans.
Plan of Correction:On date of our inspection facility could not locate the portable life safety floor plans.
The office administrator has since obtained the blueprints of the facility and made a color-coded copy that includes:
a. Smoke Barrier Walls;
b. Fire Barrier Walls;
c. Horizontal Exits;
d. Hazardous Areas;
e. Required Exits should be clearly noted; and
f. Shafts Walls
The floor plan copy is now kept in our life safety binder for easy access and to be checked and updated accordingly by the office administrator and the maintenance director.
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