Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID# 24741501
Component 01
Main Building
Based on a Relicensure Survey completed on April 24, 2024, it was determined that Azura Surgery Center South Philadelphia 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 building, that is non-sprinklered.
This is a Class "B" Ambulatory Surgical Facility.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier
Name - CLASS B ASF Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting two smoke zones within the facility.
Findings include:
Observation made on April 24, 2024, at 9:50 a.m., revealed unsealed wall penetrations around a blue data cable and electrical wiring above the ceiling, near the Restricted Area door, in the office hallway.
Exit Interview with the Administrator on April 24, 2024, at 10:15 a.m. confirmed the unsealed penetrations.
Plan of Correction:1. The unsealed wall penetrations were sealed with appropriate material.
2. Work completed May 15, 2024.
3. The FA, Safety Officer, or designee will conduct a self-assessment that includes above the ceiling inspections for unsealed penetrations in fire or smoke barriers on an annual basis.
4. The FA, Safety Officer, or designee will document their findings. Findings of inappropriately or unsealed penetrations in fire or smoke barriers will be collected and shared at the next occurring quarterly Quality Assurance Performance Improvement (QAPI) meeting and brought forth to the Governing Body (GB) annually.
28 Pa. Code § 569.2 STANDARD
Electrical Systems - Other
Name - CLASS B ASF 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 accordance with NFPA 70 Standard, National Electrical Code, in one instance, affecting one smoke compartment,
Findings include:
Observation on April 24, 2024, at 10:00 a.m., revealed abandoned electrical wires above the ceiling, outside the Medical Director's office.
Exit Interview with the Administrator on April 24, 2024, at 10:15 a.m. confirmed the abandoned electric wires.
Plan of Correction:1. The abandoned electrical wires were removed and the remaining penetration sealed with appropriate material.
2. Work completed May 15, 2024.
3. The FA, Safety Officer, or designee will conduct a self-assessment that includes above the ceiling inspections to assess for exposed wiring.
4. The FA, Safety Officer, or designee will document their findings. Findings of exposed wiring will be collected and shared at the next occurring quarterly Quality Assurance Performance Improvement (QAPI) meeting and brought forth to the Governing Body (GB) annually.
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