QA Investigation Results

Pennsylvania Department of Health
AFP SURGERY CENTER
Building Inspection Results

AFP SURGERY CENTER
Building Inspection Results For:


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Initial Comments:
Name - MAIN BUILDING Component - 01

Facility ID# 21341501
Component 01
Main Building

Based on a Relicensure Survey completed on February 8, 2019, it was determined that AFP 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 one-story, Type V(000), unprotected wood frame structure, without a basement, which is fully sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Emergency Lighting

Name - MAIN BUILDING 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 provide functional battery-powered emergency lighting within the component.

Findings include:

1. Observation on February 8, 2019, between 11:00 AM and 11:09 AM revealed the failure of battery back-up emergency lighting, in three locations within the facility:

a) 11:00 AM, battery emergency lights attached to the exit sign, over the doorway to the Kitchen;
b) 11:08 AM, battery emergency lights attached to the exit sign, over the doorway to the Doctor's Office;
c) 11:09 AM, battery emergency lights attached to the exit sign, over the doorway leading to the Waiting Room.

Interview with the Director of Nursing on February 8, 2019, at 11:30 AM confirmed the lighting failure.





Plan of Correction:

All three emergency back up lighting batteries have been changed already on 2/13/19 and are in proper working order. These include the lights above the doorway to the Kitchen, the Doctor's Office, and the Waiting Room. All emergency lights will be tested monthly to ensure they are in proper working order by the Medical Director. If he is unable to perform the test, the DON will perform the test. All monthly testing will be recorded and kept in a log.