Nursing Investigation Results -

Pennsylvania Department of Health
PHILADELPHIA WOMEN'S CENTER, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PHILADELPHIA WOMEN'S CENTER, INC.
Inspection Results For:
There are 15 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.


PHILADELPHIA WOMEN'S CENTER, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: A0101 - Component: 01 - Tag: 0000

Facility ID# 00178701
Component 01

Based on a Relicensure Survey completed on February 10, 2020, it was determined that Philadelphia Women's Center, Inc. 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 28 Pa Code 569.2.

This is an eight-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5

Observations:
Name: A0101 - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to perform an annual fire alarm system inspection within the required time frame, affecting the entire facility.

Findings include:

1. Documentation reviewed on February 10, 2020, at 8:15 a.m., revealed the facility did not perform an annual fire alarm inspection within the previous 12 months.

Interview at the exit conference with the Administrator on February 10, 2020, at 9:50 a.m., confirmed the facility did not perform annual fire alarm inspection within the previous 12 months.

Plan of Correction - To be completed: 04/15/2020

Plan of Correction:
1. The deficiency will be corrected as it relates to the individual by ensuring that building ownership maintains annual fire alarm inspection within previous 12 months at all times.
2. To protect patients and staff in similar situations, PWC Deputy Administrator will add fire alarm inspection to annual Quality Improvement Plan Calendar.
3. To ensure the problem does not recur, PWC Deputy Administrator will add fire alarm inspection to annual Quality Improvement Plan Calendar.
4. To ensure these solutions are sustained, PWC Deputy Administrator will add fire alarm inspection to annual Quality Improvement Plan Calendar.
5. This corrective action will be completed by 4.15.2020.

28 Pa. Code § 569.2 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10

Observations:
Name: A0101 - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to ensure the annual portable fire extinguisher inspector was certified, affecting the entire facility.

Findings include:

1. Documentation reviewed on February 10, 2020, at 8:15 a.m., revealed the facility could not provide certification for the portable fire extinguisher inspector who performed the facility's annual portable fire extinguisher inspection in September 2019.

Interview at the exit conference with the Administrator on February 10, 2020, at 9:50 a.m., confirmed documentation was not available.

Plan of Correction - To be completed: 04/15/2020

Plan of Correction:
6. The deficiency will be corrected as it relates to the individual by requesting that building ownership have portable extinguishers re-inspected by a certified inspector and providing a copy of proper documentation of certification.
7. To protect patients and staff in similar situations, PWC Deputy Administrator will request that building ownership have portable extinguishers re-inspected by a certified inspector and providing a copy of proper documentation of certification.
8. To ensure the problem does not recur, PWC Deputy Administrator will request proof of certification from building ownership annually at the time of inspection.
9. To ensure these solutions are sustained, PWC Deputy Administrator will request proof of certification from building ownership annually at the time of inspection.
10. This corrective action will be completed by 4.15.2020

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

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:
Name: A0101 - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested at patient care locations, affecting the entire facility.

Findings include:

1. Document review on February 10, 2020, at 8:15 a.m., revealed electrical receptacles at patient care locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. Patient care areas;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).

Interview at the exit conference with the Administrator on February 10, 2020, at 9:50 a.m., confirmed the documentation was not available.

Plan of Correction - To be completed: 03/13/2020

Plan of Correction:
11. Philadelphia Women's Center adheres to practice guidelines for moderate procedural sedation and analgesia and does not provide deep sedation or general anesthesia. Maintenance of hospital grade receptacles does not apply.

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