QA Investigation Results

Pennsylvania Department of Health
ENDOSCOPY CENTER OF CENTRAL PENNSYLVANIA, LLC
Building Inspection Results

ENDOSCOPY CENTER OF CENTRAL PENNSYLVANIA, LLC
Building Inspection Results For:


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Initial Comments:
Name - Component - --

Based on an Emergency Preparedness Survey completed on August 2, 2018, at Endoscopy Center of Central Pennsylvania, LLC, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.




Plan of Correction:




Initial Comments:
Name - MAIN BUILDING (ORIGINALLY 01 COMPONENT) Component - 02

Facility ID# 17081501
Component 02
Main Building

Based on a Recertification/Relicensure Survey completed on August 2, 2018, it was determined that Endoscopy Center of Central Pennsylvania, LLC was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).

This is a one-story, Type V (000), unprotected wood frame structure, without a basement, which is fully sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Gas and Vacuum Piped Systems - Inspection and

Name - MAIN BUILDING (ORIGINALLY 01 COMPONENT) Component - 02
Gas and Vacuum Piped Systems - Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to provide signage for the vacuum pump valve, per NFPA 99-5.1.11.2, which serves the entire facility.

Findings include:

1. Observation on August 2, 2018, at 9:20 AM revealed the Medical Vacuum System valves lacked tags identifying the name or chemical symbol for the specific vacuum system, the room or areas served, and caution to not close or open the valve except in an emergency.

Interview with the Center Director on August 2, 2018, at 9:20 AM confirmed the Medical Vacuum System valves lacked required signage.







Plan of Correction:

The required signage for vacuum pump valve was located after the inspector exited facility. A call was placed immediately to Field Office as well as photo documentation provided.
Beacon Medaes and Center Director will ensure that tag is visible with annual inspection of vacuum pump.