HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain one corridor door opening, affecting one of six smoke compartments.

Findings include:

1. Observation on March 28, 2014, at 10:42 a.m. revealed the Clean Supplies Room door lacked positive latching.

Interview with the Facilities Manager on March 28, 2014, at 10:43 a.m. confirmed the corridor opening deficiency.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of six smoke compartments.

Findings include:

1. Observation on March 28, 2014, at 10:12 a.m. revealed the door to the elevator machine room would not latch in the frame, due to tape over the door frame strike plate.

Interview with the Facilities Manager at 10:12 a.m. on March 28, 2014, confirmed the door would not latch.

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower, affecting three of six smoke compartments within the facility.

Findings include:

1. Observation on March 28, 2014, at 10:35 a.m. revealed the fire exit door hardware at the 1st floor East stair tower was damaged.

Interview with the Facilities Manager on March 28, 2014, at 10:35 a.m. confirmed the damaged fire exit hardware.

Based on observation and interview, it was determined the facility failed to maintain illuminated exit signage in one location, affecting two of six smoke compartments.

Findings include:

1. Observation on March 28, 2014, at 10:23 a.m. revealed an exit sign, within the first floor east stair tower, directed egress travel into the Lobby.

Interview with the Facilities Manager on March 28, 2014, at 10:23 a.m. confirmed the exit signage directed egress travel away from the exit.

Based on observation and interview, it was determined the facility failed to maintain building compliance in accordance with the Life Safety Code for the East Stroudsburg Ambulatory Surgery Center Campus.

Findings include:

1. Observation on March 27, 2014, at 9:44 a.m. revealed the door to the first floor Biohazard Room lacked positive latching. NFPA 101, 20.3.2, NFPA 101, 38.3.2

Interview with the Administrator on March 27, 2014, at 9:44 a.m. confirmed the door would not latch in the frame.

2. Observation on March 27, 2014, at 9:58 a.m. revealed the door to the 1st floor elevator machine room would not latch in the frame, due to tape over the door frame strike plate. NFPA 101, 20.3.2, NFPA 101, 38.3.2

Interview with the Administrator on March 27, 2014, at 9:58 a.m. confirmed the door would not latch in the frame.

Based on observation and interview, it was determined the facility failed to maintain one corridor door opening, affecting one of six smoke compartments.

Findings include:

1. Observation on March 28, 2014, at 10:42 a.m. revealed the Clean Supplies Room door lacked positive latching.

Interview with the Facilities Manager on March 28, 2014, at 10:43 a.m. confirmed the corridor opening deficiency.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of six smoke compartments.

Findings include:

1. Observation on March 28, 2014, at 10:12 a.m. revealed the door to the elevator machine room would not latch in the frame, due to tape over the door frame strike plate.

Interview with the Facilities Manager at 10:12 a.m. on March 28, 2014, confirmed the door would not latch.

Based on observation and interview, it was determined the facility failed to maintain one exit stair tower, affecting three of six smoke compartments within the facility.

Findings include:

1. Observation on March 28, 2014, at 10:35 a.m. revealed the fire exit door hardware at the 1st floor East stair tower was damaged.

Interview with the Facilities Manager on March 28, 2014, at 10:35 a.m. confirmed the damaged fire exit hardware.

Based on observation and interview, it was determined the facility failed to maintain illuminated exit signage in one location, affecting two of six smoke compartments.

Findings include:

1. Observation on March 28, 2014, at 10:23 a.m. revealed an exit sign, within the first floor east stair tower, directed egress travel into the Lobby.

Interview with the Facilities Manager on March 28, 2014, at 10:23 a.m. confirmed the exit signage directed egress travel away from the exit.

Based on observation and interview, it was determined the facility failed to maintain building compliance in accordance with the Life Safety Code for the East Stroudsburg Ambulatory Surgery Center Campus.

Findings include:

1. Observation on March 27, 2014, at 9:44 a.m. revealed the door to the first floor Biohazard Room lacked positive latching. NFPA 101, 20.3.2, NFPA 101, 38.3.2

Interview with the Administrator on March 27, 2014, at 9:44 a.m. confirmed the door would not latch in the frame.

2. Observation on March 27, 2014, at 9:58 a.m. revealed the door to the 1st floor elevator machine room would not latch in the frame, due to tape over the door frame strike plate. NFPA 101, 20.3.2, NFPA 101, 38.3.2

Interview with the Administrator on March 27, 2014, at 9:58 a.m. confirmed the door would not latch in the frame.