Initial Comments:
Name - GWV PITTSTON AMBULATORY SURGICAL CENTER Component - 01
Facility ID# 26051501
Component 01
Main Building
GWV Ambulatory Surgery Center, Pittston
Based on a Relicensure Survey completed on July 11, 2023, it was determined that Geisinger Wyoming Valley Outpatient Surgery Center, Pittston, was not in compliance with the following requirements of the Life Safety Code for new Ambulatory health care occupancy.
This is a one story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Exit Signage
Name - GWV PITTSTON AMBULATORY SURGICAL CENTER Component - 01
Exit Signage
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
20.2.10, 21.2.10, 7.10
Observations:
Based on observation and interview, it was determined the facility failed to install and maintain exit signage in one location, affecting one of two smoke compartments.
Findings include:
1. Observation on July 11, 2023, at 10:55 a.m., revealed illuminated exit signage was lacking at the Waiting Room entrance door.
Exit interview with the Facilities Manager on July 11, 2023, at 10:30 a.m., confirmed the exit signage deficiency.
Plan of Correction:Education
The HVAC Mechanic Zone/TR will review NFPA 101 and educate the facilities personnel at a staff meeting on Monday July 17 2023.
Corrective Action
An illuminated exit sign was purchased and installed at the Waiting Room door location on Tuesday July 18 2023.
Monitoring
Any changes to the layout of the building will be reviewed to ensure illuminated exit signs are in the proper location. Monthly facility rounding will include "All fire exit signs are illuminated" to ensure ongoing compliance.
Responsibility
HVAC Mechanic Zone/TR
NFPA 101 STANDARD
Fire Drills
Name - GWV PITTSTON AMBULATORY SURGICAL CENTER Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7
Observations:
Based on documentation review and interview, it was determined the facility failed to conduct fire drills on one of four required occasions, affecting two of two smoke compartments.
Findings include:
1. Observation on July 11, 2023, at 11:10 a.m., revealed the facility lacked a fourth quarter fire drill, for the calendar year, 2022.
Exit interview with the Facilities Manager on July 11, 2023, at 10:30 a.m., confirmed the fire drill deficiency.
Plan of Correction:
Geisinger Wyoming Valley Outpatient Surgery CenterPoint's "Fire Safety Management Plan" was reviewed, and no revisions were made.
Education
The Manager of Security for the Ambulatory Surgical Facility (ASF) will educate the security and facilities staff of the ASF regarding the Fire Safety Management Plan. This education will be completed at the staff meetings on July 18, 2023, July 19, 2023, and August 8th 2023 and included the requirement that fire drill frequency was to be completed on a quarterly basis.
Monitoring
A fire drill schedule was created to ensure that fire drills at the ASF are completed on a quarterly basis. 100% of fire drills will be audited by the Security Manager monthly to ensure that each quarter a fire drill was completed. Data compliance will be reported to the Regulatory PI Department and to the Safety committee as appropriate
Responsibility party
Security Manager
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