QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - 1ST FLOOR TENANT SPACE Component - 01

Facility ID # 50581501
Component 01
1st Floor Tenant Space

Based on a Relicensure Survey completed on May 4, 2021, it was determined that Advanced Surgery Center of Lancaster was not in compliance with the following requirements of the Life Safety Code for a new ambulatory health care occupancy.

This is a two-story, Type III (200), protected ordinary structure, which is fully sprinklered. The tenant space is on the ground floor.

Plan of Correction:

28 Pa. Code 569.2 STANDARD
Multiple Occupancies

Name - 1ST 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.,,,,42 CFR 416.44


Based on observation and interview, it was determined the facility failed to maintain the rating of the required tenant separation, for one of one smoke zone within the component.

Findings include:

Observation on May 5, 2021, between 11:00 AM and 11:45 AM, revealed the following unsealed penetrations of the 1-hour fire-rated tenant separation wall:

a. 11:00 AM, a 3-inch PVC pipe lacked a fire collar, above the ceiling, in the Trash Room;
b. 11:30 AM, around and inside two 1-inch conduits, above the ceiling, in the Office Manager's Office;
c. 11:45 AM, around and inside two 1-inch conduits and around PVC vent pipe, above the ceiling, in the Consultation Room.

Interview with the Administrator on May 5, 2021, at 12:00 PM confirmed the unsealed penetrations.

Plan of Correction:

We have contacted the building owners regarding the fire collar above the ceiling in the trash room as well as fire caulk the conduits as noted. Regarding quality assurance, the Administrator will confirm with property owners that there are no further penetrations in the fire wall and if so these will be corrected. This will all take place no later then 6/14/2021.