Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 27171500
Component 01
Building 01
Based on a Relicensure Survey completed on November 29, 2023, it was determined that Abington Surgical Center, LP 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 II (000), unprotected non-combustible building, that is partially sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier
Name - CLASS C 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 in one instance, affecting one of one floor.
Findings include:
1. Observation on November 29, 2023, at 10:10 a.m., revealed above the smoke doors by the mechanical room, an unsealed penetration around copper pipes.
Interview at the exit conference with the Administrator and Maintenance Director on November 29, 2023, at 10:40 a.m., confirmed the unsealed penetration.
Plan of Correction:The Center has hired an outside contractor that has repaired the unsealed penetration around copper pipes revealed above the smoke doors by the mechanical room. This repair is complete. A fire-rated sealant or appropriate material will be used to seal identified penetrations in accordance with fire safety regulations. The type of sealant will be identified and labeled at the site of the penetration.
Reports of this repair were given to the facilities coordinator and safety officer for review. It will be communicated to all future contractors that all penetrations must be properly fire sealed with the sealant identified.
The repairs will be communicated to the patient safety committee and the governing body.
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