Initial Comments:
Name - ENTIRE 4TH FLOOR Component - 01
Facility ID# 50701501
Component 01
Based on a Relicensure Survey completed on February 14, 2024, it was determined that Ambulatory Surgery Center of Bala Cynwyd was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.
This is a four story, Type II (222) fire resistive building, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Building Construction Type and Height
Name - ENTIRE 4TH FLOOR 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, the facility failed to maintain the fire resistance rating of the building construction, affecting one of four levels.
Findings Include:
Observation on February 14, 2024, at 12:30 p.m., revealed, the electrical room had an unknown expanding foam product used to fill floor and wall penetrations in multiple locations throughout the room.
Exit Interview with the Administrator on February 14, 2024, at 1:15 p.m., confirmed the unknown foam substance.
Plan of Correction:Findings Include:
Observation on February 14, 2024, at 12:30 p.m., revealed, the electrical room had an unknown expanding foam product used to fill floor and wall penetrations in multiple locations throughout the room.
On February 15, 2024 the locations of fire foam expansion in the electrical room were restructured and sealed with certified fire caulking as evidenced by the following photos:
1. Certified and rated fire caulk material
2. Electric room foam penetration repair A
3. Electric room foam penetration repair B
Listed repairs meet the respective guidelines in accordance with section 9.7 and will be confirmed to remain intact quarterly and intermittently as needed in Life Safety internal auditing.
NFPA 101 STANDARD
Subdivision of Building Spaces-Smoke Barrier
Name - ENTIRE 4TH FLOOR Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 NEW
Smoke barriers shall be constructed to provide at least a 1 hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems.
20.3.7.5, 20.3.7.6, 8.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two smoke compartments.
Findings include:
Observation on February 14, 2024, at 12:50 p.m., revealed, by the Exit sign above the smoke doors in PACU, an unsealed penetration around MC wire.
Exit Interview with the Administrator on February 14, 2024, at 1:15 p.m., confirmed the penetration.
Plan of Correction:Observation on February 14, 2024, at 12:50 p.m., revealed, by the Exit sign above the smoke doors in PACU, an unsealed penetration around MC wire.
On February 15, 2024 the locations of fire foam expansion in the PACU were restructured and sealed with certified fire caulking as evidenced by the following photos:
1. Certified and rated fire caulk material
2. PACU foam penetration repair A
3. PACU foam penetration repair B
4. PACU foam penetration repair C
5. PACU foam penetration repair D
6. PACU foam penetration repair E
7. PACU foam penetration repair F
Listed repairs meet the respective guidelines in accordance with section 9.7 and will be confirmed to remain intact quarterly and intermittently as needed in Life Safety internal auditing
|