Initial Comments:
Name - LGH AMBULATORY SURGICAL FACILITY Component - 01
Facility ID #50791501
Component 01
LGH Ambulatory Surgical Facility
Based on a Relicensure Survey completed on January 4, 2024, it was determined that Lancaster General Hospital Ambulatory Surgical Facility, was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a four-story, Type II (222), protected noncombustible structure, without a basement, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Vertical Openings - Enclosure
Name - LGH AMBULATORY SURGICAL FACILITY Component - 01
Vertical Openings - Enclosure
2012 EXISTING
Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Unenclosed openings which do not serve as a required means of egress are permitted.
3. Exit access stairs may be unenclosed if they meet the following conditions:
Two stories or less
a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1).
b. Total travel distance to outside does not exceed 100 feet.
Three stories or less
a. Occupant load per story does not exceed 15 people.
b. Building is sprinkler protected throughout per 9.7.1.1(1).
c. Building contains an automatic smoke detection system per 9.6.
d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building.
e. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain the rating of vertical chases, in one of seven chases within the component.
Findings include:
1. Observation on January 4, 2024, at 11:40 AM, revealed an unsealed penetration in the two hour chase in HT/WT Bay 14.
Interview with the Facilities Manager on January 4, 2024, at 11:40 AM, confirmed there was a penetration.
Plan of Correction:Action: Penetrations have been fire stopped with Hilti's UL rated fire assembly (Hilti's System # W-L-3065) which is an approved through-wall penetration fire stop system. Photo documentation sent as supporting back-up of work completion.
Responsible Party: Director, Facilities
Completion Date: 01/09/2024
Action: The facility will maintain the rating of the vertical chases.
Responsible Party: Director, Facilities
Completion Date: 01/09/2024
Action: Follow up meeting with Pagoda Electrical, Novastream, James Craft, JCI contractors to discuss expectations for working in hospital environments.
Responsible Party: Director, Facilities
Completion Date: 02/09/2024
Action: Prior to closing any requested above ceiling permit, facilities will conduct an inspection to ensure all work has been completed per code compliance. Results of these inspections will be reported to the LGH ASF Board.
Responsible Party: Director, Facilities
Completion Date: 02/09/2024
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier
Name - LGH AMBULATORY SURGICAL FACILITY Component - 01
Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5
Observations:
Based on observation and interview, it was determined the facility failed to maintain the rating of smoke barrier walls, affecting two of two smoke compartments within the component.
Findings include:
1. Observation on January 4, 2024, at 10:55 AM, revealed a penetration of a data wire and an M/C cable over the double smoke doors by Bay 1, in Pre/Post Ops.
Interview with the Facilities Manager on January 4, 2024, at 10:55 AM, confirmed there was a penetration.
2. Observation on January 4, 2024, at 11:25 AM, revealed a penetration of an M/C cable over the smoke door by Bay 14, in Pre/Post Ops.
Interview with the Facilities Manager on January 4, 2024, at 11:25 AM, confirmed there was a penetration.
Plan of Correction:Action: Penetrations have been fire stopped with Hilti's UL rated fire assembly (Hilti's System # W-L-3065) which is an approved through-wall penetration fire stop system. Photo documentation sent as supporting back-up of work completion.
Responsible Party: Director, Facilities
Completion Date: 01/09/2024
Action: The facility will maintain the rating of the smoke barrier walls.
Responsible Party: Director, Facilities
Completion Date: 1/9/2024
Action: Follow up meeting with Pagoda Electrical, Novastream, James Craft, JCI contractors to discuss expectations for working in hospital environments.
Responsible Party: Director, Facilities
Completion Date: 02/09/2024
Action: Prior to closing any requested above ceiling permit, facilities will conduct an inspection to ensure all work has been completed per code compliance. Results of these inspections will be reported to the LGH ASF Board.
Responsible Party: Director, Facilities
Completion Date: 02/09/2024
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier Doors
Name - LGH AMBULATORY SURGICAL FACILITY Component - 01
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Smoke barrier doors shall be a minimum of 1-3/4 inches thick, solid-bonded wood core or equivalent with self-closing or automatic-closing devices in accordance with 21.2.2.4. Latching hardware is not required. Doors are not required to swing in the direction of egress travel.
21.3.7.9, 21.3.7.10
Observations:
Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors to be unobstructed from self-closing, affecting two of two smoke compartments within the component.
Findings include:
1. Observation on January 4, 2024, at 11:20 AM, revealed the smoke barrier door from Pre/Post Ops into the Conference Room was being held open by a chock.
Interview with the Facilities Manager on January 4, 2024, at 11:20 AM, confirmed the smoke barrier doors were obstructed from self-closing.
Plan of Correction:Action: Door chock removed and disposed of in the presence of the inspector.
Responsible Party, Director, Facilities
Completion Date: 1/4/2024
Action: Daily audits completed by ASF staff to ensure doors with a self-closing or automatic closing devices (fire/smoke-rated door) are not held open. Results of these audits will be reported to the LGH ASF Board.
Responsible Party: Director, Nursing
Completion Date: 2/9/2024
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