Pennsylvania Department of Health
DERMATOLOGIC SURGICENTER - DREXEL HILL
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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DERMATOLOGIC SURGICENTER - DREXEL HILL - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: CLASS B ASF - Component: 01 - Tag: 0000

Facility ID# 05421500
Component 01
Main Building

Based on a Relicensure Survey completed on May 16, 2023, it was determined that Dermatologic Surgicenter - Drexel Hill was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a two-story, Type V (111), protected wood frame construction, with basement, which is not sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Emergency Lighting:

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:
Name: CLASS B ASF - Component: 01 - Tag: 0291

Based on observation and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition on one of two floors.

Findings include:

1. Observation on May 16, 2023, at 10:35 am, revealed the battery back-up light in the corridor by the recovery room failed to illuminate when tested.

Exit Interview with the Administrator on May 16, 2023, at 11:00 am, confirmed the battery back-up light failed to illuminate when tested.

Plan of Correction - To be completed: 06/30/2023

Our electrical contractor came for annual inspection 3/16/23. All backup lighting was operational. Our nursing staff checks the light monthly. On 5/3/23 it was functional and operating properly.

We will continue to do monthly checks. We will document in the maintenance binder. We will notify our electrical contractor if there are any malfunctioning light immediately upon discovery.

The report will be kept in the binder for Life Safety in the conference room. The medical director and head nurse will be responsible for assuring that the system is tested, maintained and properly documented.

28 Pa. Code § 569.2 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2

Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0521
Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting the entire facility.

Findings include:

1. Document review on May 16, 2023, at 10:15 am, revealed the facility lacked documentation that a four-year inspection of the fire/smoke dampers was performed.

Exit Interview with the Administrator on May 16, 2023, at 11:00 am, confirmed damper inspection documentation was not available.

Plan of Correction - To be completed: 06/30/2023

An inspection will be completed on 6/2/23 of the fire/smoke dampers by our licensed HVAC company. The report of same will be placed in the Life Safety binder. The staff will be aware of the 4 year inspection requirement. A schedule of same will be placed in the binder with the report.

The medical director and head nurse will be responsible for assuring that the inspection is completed every 4 years and proper documentation is received.

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