QA Investigation Results

Pennsylvania Department of Health
FOUR SEASONS ENDOSCOPY CENTER, INC.
Building Inspection Results

FOUR SEASONS ENDOSCOPY CENTER, INC.
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: 14671501
Component 01
Main Building

Based on a Relicensure Survey completed on February 6, 2019, it was determined that Four Seasons Endoscopy Center, Inc., was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.

This is a one-story, Type II (000), unprotected non-combustible building, that is not sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Electrical Systems -Essential Electric System

Name - MAIN BUILDING 01 Component - 01
Electrical Systems - Essential Electric System Categories
*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.
*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.
*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Observations:
Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator for one of one generators, affecting the entire facility.

Findings include:

1. Observation on February 6, 2019, at 9:30 a.m., revealed there was no emergency generator remote manual stop station located outside of the generator enclosure.

Interview with the Nurse Manager and the Practice Administrator on February 6, 2019, at 10:00 a.m., confirmed there was not a remote manual stop switch located outside of the generator enclosure.








Plan of Correction:

On February 6, 2019 it was determined that Four Seasons Endoscopy Center (Facility 14571501) was not in compliance with the Life Safety Code 28 PA Code 569.2. Refer to Observation Prefix S 0341.

In order to correct this immediately and permanently, the corporate board was notified and approved purchase of an additional component to our current generator system as it does not contain a remote emergency stop switch. Our Kohler generator is inspected and maintained by Palco company.

Palco has been contacted via telephone (on 2-6-19 and 2-15-19) to request the installation of an emergency stop switch for our generator. Once installed it will be maintained by Palco in regular intervals as part of our generator system already in place.

The timeline for corrective action to be completed is May 31, 2019. Once completed the TQI committee and the corporate board will be notified