QA Investigation Results

Pennsylvania Department of Health
COLONOSCOPY CENTER, LANSDALE, THE
Building Inspection Results

COLONOSCOPY CENTER, LANSDALE, THE
Building Inspection Results For:


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Initial Comments:
Name - ASF COLONOSCOPY CENTER Component - 01

Facility ID# 24791501
Component 01

Based on a Relicensure Survey completed on August 24, 2020, it was determined The Colonoscopy Center, Lansdale 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 non-combustible structure, which is fully sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Multiple Occupancies

Name - ASF COLONOSCOPY CENTER 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 fire resistance rating of tenant separating common walls, affecting the entire component.

Findings include:

1. Observation on August 24, 2020, at 1:25 p.m., revealed an unsealed penetration of the tenant separation wall around the sprinkler pipe, closest to the exterior wall, within the Break Room.

Interview with the Administrator on August 24, 2020, at 1:25 p.m., confirmed the unsealed penetration.








Plan of Correction:

The metallic sprinkler pipe penetration that was discovered in the facility break room above the ceiling in the 1 hour rated corridor on 8/24/2020 will be appropriately sealed to comply with current NFPA Life Safety Codes. This penetration will be repaired by 9/8/2020 using UL approved firestop system No. W-L-1146. The opening around the pipe penetration will be sealed using 3M Fire Barrier Sealant CP25WB+ which has a firestop testing rating for up to 4 hours, in accordance with ASTME 814 (UL1479) and is approved for all 1 and 2 hour commercial firewall assemblies. A minimum of 5/8" thickness of fill material will be applied within the annulas, flush with both surfaces of the wall. The penetrated area will be cleaned and returned to it's originally sealed 1 hour rated condition.
To ensure that this tenant separating 1 hour firewall corridor wall or any other rated firewall in this facility remains intact and un-penetrated, all hired contractors that are working near or around a known firewall partition will be monitored by the facility Administrator and/or Nursing Director throughout the course of the project. Furthermore, the contractor will be informed of the current NFPA Fire Safety Codes to which they must comply.
To further insure compliance, the facility Administrator and/or Nursing Director will inspect the work accomplished by the contractor prior to exiting the building.


28 Pa. Code 569.2 STANDARD
Electrical Systems -Essential Electric System

Name - ASF COLONOSCOPY CENTER 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 observation and interview, it was determined the facility failed to provide an emergency shut off for the emergency generator, affecting the entire component.

Findings include:

1. Observation on August 24, 2020, at 11:59 a.m., revealed the generator lacked a remote manual stop station outside the generator housing.

Interview with the Administrator on August 24, 2020, at 1:25 p.m., confirmed the lack of a manual emergency shut off located outside the generator housing.







Plan of Correction:

An approved manual remote emergency shut off station will be installed on the outside of the facility emergency generator housing by both a competent licensed electrician and a competent licensed emergency generator installation technician appointed by the original emergency generator installation company. This installation will be completed and tested by 9/30/2020, thereby bringing the facility emergency generator into current NFPA Life Safety Code compliance.
Going forward, the facility Administrator and/or Nursing Director will review all current NFPA Life Safety Codes to ensure that all emergency systems are following the latest codes and are up to date.

Additionally, all contractors that are hired to install or maintain standard equipment or emergency systems within the facility will be asked to ensure via ongoing and regular inspections, that this equipment is updated to maintain or achieve the latest NFPA Life Safety standards and report to the facility Administrator and/or Nursing Director any deviations. To ensure ongoing safety, the facility Administrator and/or Nursing Director will review all PA DOH Life Safety bulletins available, initiating and documenting any needed changes in a timely manner.