QA Investigation Results

Pennsylvania Department of Health
CORNERSTONE AMBULATORY SURGERY CENTER LLC
Building Inspection Results

CORNERSTONE AMBULATORY SURGERY CENTER LLC
Building Inspection Results For:


There are  14 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 - CLASS C ASF Component - 01

Facility ID# 21331501
Component 01
Main Building

Based on a Relicensure Survey completed on August 9, 2018, it was determined that Cornerstone Ambulatory Surgery Center, 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 construction, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.


Plan of Correction:




28 Pa. Code 569.2 STANDARD
Emergency Lighting

Name - CLASS C ASF 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 document review and interview, it was determined the facility failed to ensure battery back-up lighting was tested at required intervals, affecting two of two O.R.'s within the facility

Findings include:

1. Document review on August 9, 2018, between 8:00 am, and 9:30 am, revealed, documentation verifying an annual 90-minute test of the back-up lighting in O.R. 1 and O.R. 2 was not available at time of survey.

Interview at the exit conference with the Administrator on August 9, 2018, at 12:00 pm, confirmed documentation of the 90-minute test was not available.




Plan of Correction:

#0291
Fidelity Alarm Co completed our semi annual inspection on 7/26/18. The 90 minute lighting inspection was not completed. Fidelity was called to confirm the lighting inspection and we were advised it was overlooked. We immediately set up an inspection for 8/16/2018, the testing was completed on that date and certification is on file. We will discuss this at our next staff meeting and make sure that this is included in our second semi annual inspection moving forward.
This will be hi-lighted on our maintenance schedule to ensure that the 90 minute testing will be completed.
The DON will be responsible for monitoring ongoing compliance.


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

Name - CLASS C ASF 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 sprinkler components within a smoke tight assembly on one of one floor within the facility.

Findings include:

1. Observation on August 9, 2018, at 11:10 am, revealed, in the corridor near the operating rooms, gaps around two sprinklers, which could delay activation of the sprinklers.

Interview at the exit conference with the Administrator on August 9, 2018, at 12:00 pm, confirmed the gaps around the sprinklers.



Plan of Correction:

#0353
G.C. Inc. Mechanical Contractors completed their quarterly inspection on 7/12/2018, the report was not available at the time of the building inspection, it is currently on file.
We have called G.C. Inc. Mechanical Contractors to set up an appointment to repair the sprinkler head gaps in the corridor near the operating rooms and to inspect all sprinkler heads throughout the building.
This will be discussed at our next staff meeting and will continue to be checked on our preventative Maintenance Checklist.
The DON will be responsible for monitoring ongoing compliance.


28 Pa. Code 569.2 STANDARD
Fire Drills

Name - CLASS C ASF Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7

Observations:

Based on documentation review and interview, it was determined the facility failed to conduct quarterly fire drills in one out of four quarters in the last year.

Findings Include:

1. Document review on August 9, 2018, between 8:00 am, and 9:30 am, revealed the facility did not perform a fire drill during the 3rd quarter of year 2017.

Interview at the exit conference with the Administrator on August 9, 2018, at 12:00 pm, confirmed the fire drill documentation could not be produced at the time of the survey.




Plan of Correction:

#0712
Fire drills should be performed at various unexpected times on a quarterly basis. One was missed in the third quarter of 2017.
We will hi-light this requirement on our monthly maintenance checklist, two have been performed this year and we will perform a third one in the next few weeks.
We will discuss this at our next staff meeting.
The DON will be responsible to conduct these drills.


28 Pa. Code 569.2 STANDARD
Electrical Systems - Other

Name - CLASS C ASF Component - 01
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.

Observations:

Based on document review and interview, it was determined the facility failed to maintain working space around electrical equipment on one of one floors within the facility.

Findings include:

1. Observation on August 9, 2018, at 10:45 am, revealed, in the recovery room, a stretcher bed parked in front of the electrical panels, prohibiting access to the panels.

Interview at the exit conference with the Administrator on August 9, 2018, at 12:00 pm, confirmed

~Refer to the NFPA 70 National Electrical Code, Section 110.26




Plan of Correction:

#0911
The stretcher has been removed from the front of the electrical panels.
This will be discussed at our next staff meeting so that all staff will be aware that nothing is permitted to be within 3 feet of any electrical panel.
This will be monitored by our monthly walk arounds to check for compliance.
The DON will be responsible for monitoring ongoing compliance.