Initial Comments:
Name - FIRST FLOOR TENANT SPACE Component - 01
Facility ID# 50511501
Component 01
Based on a Relicensure Survey completed on August 31, 2020, it was determined Bucks County Surgical Suites was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory Health Care Occupancy.
This is a three-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Multiple Occupancies
Name - FIRST FLOOR TENANT SPACE 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 ensure the tenant separation maintained a fire resistance rating, affecting one of three levels within the facility.
Findings include:
1. Observation on August 31, 2020, between 10:41 a.m. and 10:55 a.m., revealed unsealed penetrations of the tenant separation at the following locations:
a. 10:41 a.m., there was an unsealed penetration by a data wire, above the exit door, near the medical gas storage room;
b. 10:55 a.m., there was an unsealed penetration by a data wire, above the lobby door.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed unsealed penetrations.
Plan of Correction:The data wire penetrations (1.a and 1.b.) have been filled with Fire Rated caulk in accordance with the 1 hour fire rating requirement. This work was done on Wednesday, September 2.
The administrator of the facility oversees any work that must be done in the facility and is responsible for assuring all work meets code. The data penetration cables were from the original construction phase; no work has been done in the ceiling since construction.
NFPA 101 STANDARD
Means of Egress - General
Name - FIRST FLOOR TENANT SPACE Component - 01
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1
Observations:
Based on document review and interview, it was determined the facility failed to provide procedures on maintenance of exits, affecting three of three exits from the facility.
Findings include:
1. Document review on August 31, 2020, between 8:30 a.m. and 10:00 a.m., revealed the facility lacked a written snow removal policy to maintain exits clear of obstructions.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the missing snow removal policy.
Plan of Correction:The surgical suite is located within a 3 story office building. The snow removal is part of the grounds maintenance and lease with the landlord and building association. The landlord's snow removal policy was received on September 9, 2020 and has been affixed to the surgical suites policy and procedures.
The contracted service is on site before a snow and/or ice event begins and consistently throughout the day.
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - FIRST FLOOR TENANT SPACE Component - 01
Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7
Observations:
Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures with smoke resistive separation, affecting two hazardous locations within the ambulatory surgical facility.
Findings Include:
1. Observation on August 31, 2020, at 11:25 a.m., revealed the storage room door lacked self-closing hardware and was not smoke tight around the perimeter. This room was previously designated as a patient changing area.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the hazardous area lacked smoke tight separation.
2. Observation on August 31, 2020, at 11:45 a.m., revealed the door to the soiled work room did not positively latch into its frame when closed.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the hazardous area door required adjustment.
Plan of Correction:The door latch was serviced and repaired by a contractor on Thursday, September 10, 2020.
Monthly door checks are done by the administrator and this door continues to operate correctly since the repair.
NFPA 101 STANDARD
Portable Fire Extinguishers
Name - FIRST FLOOR TENANT SPACE Component - 01
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10
Observations:
Based on observation, document review and interview, it was determined the facility failed to maintain required inspections for portable fire extinguishers, affecting the entire ambulatory surgical facility.
Findings include:
1. Observation on August 31, 2020, between 11:14 a.m. and 12:00 p.m., revealed monthly visual inspections were not documented for fire extinguishers throughout the facility.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the missing monthly inspection.
Plan of Correction:The fire extinguishers are inspected monthly by the administrator of the facility and the inspections are documented in a binder. The tags on the individual fire extinguishers have been updated with the date and signatures as requested.
The administrator of the facility will document the inspection on the tags as required.
NFPA 101 STANDARD
HVAC
Name - FIRST FLOOR TENANT SPACE Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Based on observation and interview, it was determined the facility failed to properly install Heating, Ventilation and Air Conditioning equipment (HVAC), affecting one location within the ambulatory surgical facility.
Findings include:
1. Observation on August 31, 2020, at 10:40 a.m., revealed a flexible supply duct inside the electrical room was supported by flexible metal conduit in lieu of the deck above.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the improperly supported conduit.
Plan of Correction:The flexible HVAC duct has been relocated to below the metal electrical conduit and the HVAC duct is now supported by the HVAC system above.
The administrator oversees any contracted work at the surgical suites.
NFPA 101 STANDARD
Gas and Vacuum Piped Systems - Other
Name - FIRST FLOOR TENANT SPACE 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 document review and interview, it was determined the facility failed to maintain labeling of the piped-in medical gas system, in accordance with NFPA 99, Health Care Facilities Code, Section 5.1.11.1.2, affecting one location within the facility.
Findings include:
1. Observation on August 31, 2020, at 11:05 a.m., revealed the medical gas oxygen supply line, inside the bay, near the stair exit door, inside Pre/Post Op, lacked labeling at the branch line, above the ceiling.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the missing labels.
Plan of Correction:The surgical suites has scheduled a Medical Gas contractor to apply the correct labeling and the work is scheduled to be done tomorrow, September 25, 2020. All medical gas supply lines will be labeled at the branch lines, above the ceiling, as required.
The administrator of the facility oversees all contracted work to ensure the work is done to meet the standards.
NFPA 101 STANDARD
Electrical Systems - Other
Name - FIRST FLOOR TENANT SPACE Component - 01
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 6 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, in accordance with NFPA 70, National Electric Code, affecting one location within the ambulatory surgical facility.
Findings include:
1. Observation on August 31, 2020, at 11:20 a.m., revealed abandoned wiring above the ceiling inside the Men's Staff Toilet.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the abandoned wiring.
Plan of Correction:The abandoned wire was removed from the ceiling on September 23, 2020. This wire had been cut and left in the ceiling during the construction phase of the building.
All contracted work in the facility is overseen by the administrator to ensure that the work is done according to the standards.
NFPA 101 STANDARD
Electrical Systems-Essential Electric System
Name - FIRST FLOOR TENANT SPACE Component - 01
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10-seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Based on observation and interview, it was determined the facility failed to maintain required inspections as well as clear and unobstructed access to the emergency generator, affecting the entire ambulatory surgical facility.
Findings include:
1. Observation on August 31, 2020, between 10:10 a.m. and 10:15 a.m., revealed the following deficiencies of the emergency generator:
a. 10:10 a.m., the access doors were partially blocked by shrubs;
b. 10:15 a.m., the emergency generator remote stop button was blocked by a shrub.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the above emergency generator deficiencies.
Plan of Correction:The deficiencies noted (1.a. and 1.b.) have been cut back as requested. The work was complete on September 2, 2020. The generator access doors are easily accessed and the remote stop is easily viewed and accessed.
The administrator has added a checkbox to the weekly run sheet to ensure that access to both the doors and the remote switch are both clear.
The facility administrator oversees the weekly generator checks and is responsible for being sure the shrubs are maintained.
NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag
Name - FIRST FLOOR TENANT SPACE Component - 01
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to maintain the enclosure of medical gas cylinders, affecting one manifold room within the facility.
Findings Include:
1. Observation on August 31, 2020, at 10:23 a.m., revealed the door to the medical gas storage room did not positively latch within its frame when closed.
Interview at the exit conference with the Administrator on August 31, 2020, at 12:00 p.m., confirmed the medical gas storage door required adjustment to latch.
Plan of Correction:The door was repaired on September 10, 2020, by a contractor.
The doors are checked monthly by the administrator for proper functioning and latching. The facility administrator is responsible for the working condition of the doors.
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