QA Investigation Results

Pennsylvania Department of Health
AZURA SURGERY CENTER NORTHEAST PHILADELPHIA
Building Inspection Results

AZURA SURGERY CENTER NORTHEAST PHILADELPHIA
Building Inspection Results For:


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Initial Comments:
Name - CLASS C ASF Component - 01

Facility ID# 24731501
Component 01
Main Building

Based on a Relicensure Survey completed on January 28, 2019, it was determined that Azura Surgery Center Northeast Philadelphia 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 III (200), unprotected ordinary structure, which is fully sprinklered.


Plan of Correction:




28 Pa. Code 569.2 STANDARD
Electrical Systems - Maintenance and Testing

Name - CLASS C ASF Component - 01
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:

Based on documentation review and interview it was determined the facility failed to provide annual receptacle testing in patient care rooms at bed locations within this facility.

Findings include:

Document review on January 28, 2019, at 8:45 am, revealed the facility was unable to provide documentation showing annual receptacle testing at patient bed locations was performed during the previous 12 months.

Interview at the exit conference with the Administrator and Regional Director on January 28, 2019 at 10:00 am, confirmed the documentation was unavailable.











Plan of Correction:

Plan of Action:
Facility was unable to provide documentation showing annual receptacle testing at patient bed locations was performed during the previous 12 months.

Facility contracted with vendor to conduct Maintenance and Testing for all Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered throughout the center, for compliance and meeting safety code; 6.3.4 (NFPA 99).
Vendor completed testing on 02/04/2019; with completed associated report to be made available upon request.
Facility Administrator will conduct quarterly survey of center as part of the Environment of Care for the center to include review of the records for the Electrical Receptacles testing.
These records will be reviewed at the QAPI (Quality Assurance, Performance and Improvement) committee meeting and reported to Governing Body to review and approval.
Failure of such actions by the Facility Administrator will be addressed by the Governing Body.