Initial Comments:
Name - GI OUTPATIENT ENDOSCOPY CENTER Component - 01
Facility ID# 50661501
Component 01
GI Outpatient Endoscopy Center
Based on a Relicensure Survey completed on December 14, 2023, it was determined that Penn Digestive And Liver Health Center University City was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.
This is a thirteen story, Type I (222) fire resistive building, with a basement and a penthouse, that is fully sprinklered.
Approved as a Class C Ambulatory Surgical Facility.
Plan of Correction:
NFPA 101 STANDARD
Means of Egress - General
Name - GI OUTPATIENT ENDOSCOPY CENTER 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 documentation review and interview, it was determined the facility failed to maintain fire rated door openings, affecting one of thirteen levels.
Findings include:
Document review on December 14, 2023, at 9:30 a.m., revealed the June 2023, Annual Fire Door Inspection report listed 3- doors as deficient. Evidence of corrective action was not available at time of survey.
Exit Interview with the Project Manager and Plant Operations Manager, on December 14, 2023, at 11:15 a.m., confirmed the rated door deficiencies.
Plan of Correction:Plan of Correction:
0211 Deficiency
Correction of Deficiency
The Department of Engineering, overseen by the Facilities Director, is responsible for maintaining fire doors, and took the following actions:
Immediate Plan of Correction:
The Facilities Director contacted an outside vendor to order and install three doors as listed below. The doors will be replaced by January 28, 2024, to comply with the regulations and ensure they are fire-rated.
A. Door 11/7 not rated per Life Safety drawings; requires replacement.
B. Door 11/11 not rated per Life safety drawings; requires replacement.
C. Door 11/12 not rated per Life safety drawings; requires replacement.
Actions to Prevent a Re-occurrence:
The PPMC Facilities Director will meet with the team that conducts the annual fire door inspections to ensure the inspectors completing the report follow the procedures to meet regulations. The PPMC Facilities Director will verify all fire doors in the Penn Medicine University City 11th floor are included in existing annual fire door inspections and preventative Maintenance (PMs) to ensure compliance is sustained.
When the outside vendor installs the above 3 doors, he will also confirm that all remaining fire doors are compliant with to code, completed on or before January 28, 2024.
Routine Environment of Care (EOC) rounds will also be conducted in the 3737 building, 11th floor, by the EOC Life Safety Committee members – there will be random reviews of fire doors to ensure the doors are compliant to meet code/regulation.
Performance Improvement and Reporting:
Quarterly data from the EOC rounding inspections will be submitted, along with an annual fire door report, confirming compliance with the Patient Safety and Quality Committees for the Penn Digestive and Liver Health Center University City as part of the ongoing Quality Assurance and Performance Improvement program until compliance is sustained at least annually.
Responsible Party:
Assistant Vice President of Facilities
Completion Date for Replacement of Doors:
January 28, 2023
NFPA 101 STANDARD
HVAC
Name - GI OUTPATIENT ENDOSCOPY CENTER 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 document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting one of thirteen levels.
Findings include:
Document review on December 14, 2023, at 9:30 a.m., revealed the January 2023, fire damper inspection report listed 1-damper as failed. Evidence of corrective action was unavailable at time of survey.
Exit Interview with the Project Manager and Plant Operations Manager, on December 14, 2023, at 11:15 a.m., confirmed the missing documentation.
Plan of Correction:Plan of Correction:
0521 Deficiency Correction of Deficiency
Immediate Plan of Correction:
The Department of Engineering, overseen by the Facilities Director, is responsible for maintaining fire damper maintenance and took the following actions:
The Facilities Director contacted an outside vendor to repair damper 23006 on the 11th floor of the building. The repair will be completed on or before January 5, 2024.
Actions to prevent re-occurrence: The Director of Facilities will review and confirm any identified deficiencies from a damper are repaired and reported as operational upon completion.
Performance Improvement and Reporting:
Outcomes of annual inspection and repair reports from the 11th floor where the PDLH ASF is located will be reviewed and submitted to Patient Safety and Quality Committees for the Penn Digestive and Liver Health Center University City as part of the ongoing quality assurance and performance improvement activities until compliance is sustained at least annually.
Responsible Party:
Assistant Vice President of Facilities
Repair Completed By:
January 5, 2023
NFPA 101 STANDARD
Gas and Vacuum Piped Systems - Maintenance
Name - GI OUTPATIENT ENDOSCOPY CENTER Component - 01
Gas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
Observations:
Based on document review and interview, it was determined the facility failed to maintain the medical gas system, affecting one of one medical gas system.
Findings include:
Document review on December 14, 2023, at 9:30 a.m., revealed the June 2023, Medical Gas Report indicated: "MGS found that GI does not have a code compliant master alarm and proper source signals require installment." Proof of corrective action was not available at time of survey.
Exit Interview with the Project Manager and Plant Operations Manager, on December 14, 2023, at 11:15 a.m., confirmed the medical gas deficiency.
Plan of Correction:Plan of Correction:
0907
Immediate Plan of Correction:
The Engineering Department, overseen by the Director of Facilities, maintains documentation to verify master alarm indicators are reporting accurately. This program includes an inventory of all source systems and control valve alarms.
The compliance documentation was obtained on December 14, 2023, post-survey, and submitted for the Division of Safety Inspection Review. The documentation demonstrates the required NFPA99 code has been met regarding the master alarm panel on the 11th floor of the facility.
The annual inspection report had a note stating an upgrade to the current panel is required. As per NFPA99 2012 Edition citation 5.2.9, "Warning Systems (Category 2) states;
Warning systems associated with Category 2 systems shall provide the master, area, and local alarm functions of a Category 1 system as required in 5.1.9, except as follows:
1. Warning systems shall be permitted to be a single alarm panel.
2. Alarm panel shall be located in an area of continuous surveillance while the facility operates.
3. Pressure and vacuum switches/sensors shall be mounted at the source of equipment with pressure indicator at the master alarm panel.
With remote monitoring system in place with maintenance, this satisfies that code requirement.
Actions to prevent re-occurrence: The Director of Facilities will review and confirm any identified deficiencies from any reports as identified by the inspector or medical gas vendor. The Director will confirm medical gas is operational and meets regulations on an ongoing basis.
Performance Improvement and Reporting:
Outcomes of inspection related to medical gas reports from the 11th floor where the PDLH ASF is located will be reviewed and submitted to Patient Safety and Quality Committees for the Penn Digestive and Liver Health Center University City as part of the ongoing quality assurance and performance improvement activities until compliance is sustained at least annually.
Responsible Party:
Assistant Vice President of Facilities
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