Nursing Investigation Results -

Pennsylvania Department of Health
DERMATOLOGIC SURGICENTER - PHILADELPHIA
Building Inspection Results

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DERMATOLOGIC SURGICENTER - PHILADELPHIA
Inspection Results For:

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DERMATOLOGIC SURGICENTER - PHILADELPHIA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on February 13, 2020, it was determined Dermatologic Surgicenter - Philadelphia was not in compliance with the requirements of 42 CFR 416.54.




 Plan of Correction:


416.54 CONDITION Establishment of the Emergency Program (EP):Not Assigned
The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements:

*[For hospitals at 482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

*[For CAHs at 485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:
Observations:
Name: - Component: -- - Tag: 0001

Based on document review and interview, it was determined the facility failed to develop an emergency preparedness program, affecting the entire facility.

Finding include
1. Document review on February 13, 2020, at 8:00 a.m., revealed the facility failed to establish and maintain a comprehensive emergency preparedness program in accordance with 42 CFR 416.54 condition of participation to include the following standards:

(a) Emergency Plan
(b) Policies and Procedures
(c) Communication Plan
(d) Training and Testing

Interview with the Director of Nursing on February 13, 2020, at 11:20 a.m., confirmed the facility failed to establish an emergency preparedness plan, required to be in-place by November 15, 2017.





 Plan of Correction - To be completed: 02/26/2020

Our facility Emergency Preparedness plan binder will be kept on site at all times. We will inservice all employees regarding the regulation of never removing office documentation from the facility by 2/26/20. We will develop a formal policy regarding the same by 2/26/20. The charge nurse and office manager will be responsible to ensure all Dermatologic SurgiCenter paperwork remains in house.
Initial comments:Name: CLASS B ASF - Component: 01 - Tag: 0000


Facility ID #04841500
Component 01

Based on a Recertification/Relicensure Survey completed on February 13, 2020, it was determined Dermatologic Surgicenter - Philadelphia 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 four story, Type V (111), protected wood frame construction, with a basement, which is non-sprinklered.

Approved as a Class B Ambulatory Surgical Facility (ASF).




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies:Not Assigned
Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44
Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to provide a distinct waiting room for the ambulatory surgical center patients, within the confines of a one hour tenant separation wall, affecting the entire facility.

Findings include:

1. Observation on February 13, 2020, at 8:00 a.m., revealed the surgery center shares a waiting room and reception area with the medical practice.

Interview at the exit conference with the Director of Nursing on February 13, 2020, at 11:20 a.m., confirmed the surgical waiting area was not distinctly separated from other entities.





 Plan of Correction - To be completed: 03/04/2020

On March 20, 2012, CMS granted a time limited waiver to our facility regarding ASC Waiting Area separation. It was approved. A reapplication was sent on 4/4/2017. We will reapply for a continuation of the time limited waiver by 3/4/2020.

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