Initial Comments:
Name - MUVE CHADDS FORD Component - 01
Facility ID# 29481501
Component 01
Based on a Relicensure Survey completed on June 5, 2023, it was determined that Muve - Chadds Ford Ambulatory Surgical Center, Llc was not in compliance with the following requirements of the Life Safety Code for a new ambulatory health care occupancy.
This is a one-story, Type II (000), unprotected noncombustible structure, with an unused attic space, which is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Multiple Occupancies
Name - MUVE CHADDS FORD 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 of tenant separating common walls, affecting the entire component.
Findings include:
1. Observation on June 5, 2023, at 12:57 PM, revealed drywall missing above the I-beam, located at the intersection of the tenant separation wall and the outside wall, in the Waiting Room.
Interview with the Administrator on June 5, 2023, at 12:57 PM, confirmed the missing section of drywall.
2. Observation on June 5, 2023, at 1:03 PM, revealed multiple penetrations of the tenant separation wall, located above the Main Entrance door, around electrical cables, wires and conduits.
Interview with the Administrator on June 5, 2023, at 1:03 PM, confirmed the unprotected penetrations of the tenant separation wall.
3. Observation on June 5, 2023, at 1:07 PM, revealed a 2-inch by 2-inch cut out within the tenant separation wall, located in the vestibule, on the common area side of the Patient Lavatory.
Interview with the Administrator on June 5, 2023, at 1:07 PM, confirmed the missing section of drywall.
Plan of Correction:The facilities maintenance team commenced repairs on 6/19/23 and will complete the project by 7/15.23. For the areas noted in the report the ceiling tiles were removed, and fire stopping materials (Hilti) were used to patch and seal the penetrations/openings. The team is then systematically inspecting all the rated walls within the ASC and making any necessary repairs.
When any work is to be done above ceiling the vendors will be notified of their responsibility to adhere to all code requirements to prevent any future issues. Any deficiencies identified will be reported to the Administrator who will report to QAPI inclusive of the corrective actions.
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