QA Investigation Results

Pennsylvania Department of Health
ASSOCIATES SURGERY CENTERS, L.L.C.
Building Inspection Results

ASSOCIATES SURGERY CENTERS, L.L.C.
Building Inspection Results For:


There are  23 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 50361501
Component 01
Main Building

Based on a Relicensure Survey completed on October 31, 2023, at Associates Surgery Centers, LLC, it was determined that the facility was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Healthcare Occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).

This is a two-story, Type II (000), unprotected non-combustible building that is fully sprinklered.





Plan of Correction:




28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - MAIN BUILDING Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation and interview, it was determined that the facility failed to maintain automatic sprinkler systems in one instance, affecting one of two smoke compartments.

Findings include:

1. Observation on October 31, 2023, at 9:26 a.m., revealed multiple ceiling penetrations filled with an unapproved sunstance in the electrical room on the first floor.

Interview with the Facility Administrator and Maintenance Director on October 31, 2023, at 9:26 a.m., confirmed the sprinkler system deficiencies.









Plan of Correction:

The penetrations in the ceiling in the electrical room have been repaired using 3M Fire Barrier Moldable Putty Stix MP+. The material is certified as a firestop material for electrical areas.