QA Investigation Results

Pennsylvania Department of Health
EVANGELICAL AMBULATORY SURGICAL CENTER, L.L.C.
Building Inspection Results

EVANGELICAL AMBULATORY SURGICAL CENTER, L.L.C.
Building Inspection Results For:


There are  18 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - MAIN BUILDING 01 Component - 01

Facility ID# 14631501
Component 01
Building 01

Based on a Relicensure Survey completed on October 9, 2018, it was determined that Evangelical Ambulatory Surgery Center, was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a three story, Type II (111), protected, noncombustible building, that is fully sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Means of Egress - General

Name - MAIN BUILDING 01 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 document the annual inspection of all fire rated doors affecting three of three floors within the facility.

Findings include:

1. Review of documentation on October 9, 2018, at 10:00 a.m., revealed the facility lacked a required annual fire door inspection report.

Exit interview with the facility representative #1 on October 9, 2018, between 11:30 a.m. and 11:45 a.m., confirmed the lack of a report.





Plan of Correction:

S0211
1) Review of documentation on October 9, 2018, at 10:00 a.m., revealed the facility lacked a required annual fire door inspection report.
a) Brand Services Inc. has been contracted to perform a complete fire door inspection and produce a corresponding report. ECH staff will monitor and assist in this inspection.
b) Fire door inspection report will be produced from Brand Services Inc. and supplied to ECH by 11/30/2018.
c) All corrections within the report will be tracked with the corrective work orders and photographs.
d) A tracking inspection report will be established to monitor and identify all upcoming inspections. This will be monitored and tracked through Plant Engineering.
e) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12-month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.



28 Pa. Code 569.2 STANDARD
Emergency Lighting

Name - MAIN BUILDING 01 Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9

Observations:

Based on observation and interview, it was determined the facility failed to maintain battery powered emergency lighting units on one of three floors in the facility.

Findings include:

1. Observation on October 9, 2018, at 10:05 a.m., revealed the facility lacked battery powered emergency lighting units in the two procedure rooms, which would automatically illuminate in the event of a normal power disruption.

Exit interview with the facility representative #1 on October 9, 2018, between 11:30 a.m. and 11:45 a.m., confirmed the lack battery back-up emergency lighting.





Plan of Correction:

Observation on October 9, 2018, at 10:05 a.m., revealed the facility lacked battery powered emergency lighting units in the two procedure rooms, which would automatically illuminate in the
event of a normal power disruption.
a) In-house staff will install battery operated emergency lighting in the two procedure rooms.
b) Corrections will be made through a corrective work order and will be completed by November 30, 2018.
c) All corrections will be tracked with the corrective work order and photographs.
d) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12 month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12 month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.



28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - MAIN BUILDING 01 Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of three floors.

Findings include:

1. Observation on October 9, 2018, at 10:25 a.m., revealed a group of wires located within the first floor, rear entrance corridor, tied to the sprinkler pipe brackets.

Exit interview with the facility representative #1 on October 9, 2018, between 11:30 a.m. and 11:45 a.m., confirmed the wires tied to the sprinkler piping.





Plan of Correction:

1) Observation on October 9, 2018, at 10:25 a.m., revealed a group of wires located within the first floor, rear entrance corridor, tied to the sprinkler pipe brackets.
a) Wires will be re-routed and secured away from sprinkler system. This will be performed by in-house staff.
b) Corrections will be made through a corrective work order and will be completed by November 30, 2018.
c) All corrections will be tracked with the corrective work order and photographs.
d) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12 month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12 month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.



28 Pa. Code 569.2 STANDARD
HVAC

Name - MAIN BUILDING 01 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 documentation review, and interview it was determined the facility failed to maintain key components of the heating, ventilation and cooling (HVAC) system affecting the entire facility.

Findings include:

1. Review of documentation on October 9, 2018, at 9:35 a.m., revealed the facility lacked records to support the required four-year testing and inspection of HVAC fire/smoke dampers.

Exit interview with the facility representative #1 on October 9, 2018, between 11:30 a.m. and 11:45 a.m., confirmed the lack of documentation.





Plan of Correction:

1) Review of documentation on October 9, 2018, at 9:35 a.m., revealed the facility lacked records to support the required four-year testing and inspection of HVAC fire/smoke dampers.
a) The fire/smoke dampers will be tested and inspected by in-house staff. A report will be generated with any deficiencies.
b) Corrections will be made through a corrective work order and will be completed by November 30, 2018.
c) All corrections will be tracked through the smoke damper inspection log.
d) A tracking inspection report will be established to monitor and identify all upcoming inspections. This will be monitored and tracked through Plant Engineering.
e) Evangelical Community Hospital (ECH) has a Life Safety Committee that inspects the hospital departments on a 12-month rotational basis and looks for life safety violations such as this one. A random survey is conducted in each department within the 12 month period. Results from the inspections are documented. Deficiencies are converted to work orders and remediated using approved methods by the Plant Engineering Department or outside contractors. The findings are presented to the Safety Committee and the affected department heads.