QA Investigation Results

Pennsylvania Department of Health
CHILDREN'S DENTAL SURGERY OF BETHLEHEM
Building Inspection Results

CHILDREN'S DENTAL SURGERY OF BETHLEHEM
Building Inspection Results For:


There are  5 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - NEW ASC Component - 01

Facility ID# 50451501
Component 01
Main Building

Based on a Relicensure Survey completed on September 9, 2020, it was determined that Children's Dental Surgery of Bethlehem, 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 building, that is fully sprinklered..



Plan of Correction:




28 Pa. Code 569.2 STANDARD
Building Construction Type and Height

Name - NEW ASC Component - 01
Building Construction Type and Height
Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively.


Construction Type
1 I (442), I (332), II (222), Any number of stories
II (111), III (211), IV (2HH), non-sprinklered or sprinklered
V (111)

2 II (000), III (200), V (000) One story non-sprinklered
Any number of stories sprinklered

Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met:
1. Such levels are under the control of the ambulatory health care occupancy.
2. Hazardous spaces are protected per section 8.7.
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2

Observations:

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in four locations, affecting one of one floor.

Findings include:

1. Observation on September 9, 2020, between 10:35 a.m. and 11:10 a.m., revealed the following:

a. 10:35 a.m., the facility lacked documentation denoting the flame spread rating of the exterior canopy.
b. 10:40 a.m., combustible, foam insulating materials sealed large conduit penetrations of the suite separation wall in the Pre/Post-Op area.
c. 10:55 a.m., combustible paper backing was affixed to insulation at the portion of the tenant separation wall, located within the dental storage room.
d. 11:10 a.m., combustible, foam insulating materials were used to seal various penetrations of the suite separation wall, located in the locker room corridor area.

Exit interview with the facility administrator on September 9, 2020, between 11:35 a.m. and 11:45 a.m., confirmed the building construction deficiencies.




Plan of Correction:

a. Flame spread certificate for awning has been located and will be kept on file for reference.

b. Combustible foam insulation located in the ceiling in the pre/post-operative area along the conduit penetrations will be removed and replaced with non-combustible rated caulk. Real Services was contacted and will be out the week of September 14 to make these corrections.

c. Combustible paper backing affixed to the tenant separation wall near the dental storage room will either be removed or capped to ensure that it is not exposed. Real Services was contacted and will be out the week of September 14 to make these corrections.

d. Combustible foam insulation located in the ceiling in the locker room corridor along the conduit penetrations will be removed and replaced with non-combustible rated caulk. Real Services was contacted and will be out the week of September 14 to make these corrections.




28 Pa. Code 569.2 STANDARD
Emergency Lighting

Name - NEW ASC Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9

Observations:

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting, affecting one of one floor

Findings include:

1. Observation on September 9, 2020, at 10:20 a.m., revealed the facility lacked yearly ninety-minute testing data for emergency lighting.

Exit interview with the facility administrator on September 9, 2020, between 11:35 a.m. and 11:45 a.m., confirmed the emergency lighting deficiency.




Plan of Correction:

The monthly facility maintenance log will now include an annual 90-minute test for emergency lighting per NFPA 101 Standards.


28 Pa. Code 569.2 STANDARD
Gas and Vacuum Systems - Other

Name - NEW ASC Component - 01
Gas and Vacuum Piped Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 5 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to properly install and maintain medical gas piping, affecting one of one floor.

Findings include:

1. Observation on September 9, 2020, at 11:00 a.m., revealed medical gas piping located in the rear exit access corridor was not separated from dissimilar metals (resided atop metal struts with no separation).

Exit interview with the facility administrator on September 9, 2020, between 11:35 a.m. and 11:45 a.m., confirmed the medical gas piping deficiency.





Plan of Correction:

The medical gas piping located in the receiving area was noted to lack insulating material between similar metals. Red Lion was contacted to remediate this deficiency and will be on site the week of September 14. Insulating material will be applied to provide separation of medical gas piping from the metal struts that support this piping.