Pennsylvania Department of Health
WILLS EYE SURGERY CENTER OF PLYMOUTH MEETING
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 31 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.


WILLS EYE SURGERY CENTER OF PLYMOUTH MEETING - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID# 07451500
Component 01

Based on a Relicensure Survey completed on May 28, 2025, it was determined that Wills Eye Surgery Center Of Plymouth Meeting 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 II (000), unprotected non-combustible building, that is fully sprinklered.

This is a Class C Ambulatory Surgical Facility.

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 C ASF - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to ensure battery back-up lighting was tested at required intervals, for one of one required test.

Findings include:

Document review on May 28, 2025, at 9:30 a.m., revealed documentation verifying an annual 90-minute test of the battery back-up lighting was not available at time of survey.

Exit Interview with the Administrator on May 28, 2025, at 11:45 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 06/27/2028

A 90 minute test of battery back up lighting will now be done with our electrical check yearly, by our electrical inspector Andy Talone. This years test will be done by 6/27/28.

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: CLASS C ASF - Component: 01 - Tag: 0345

Based on document review and interview, it was determined the facility failed to maintain smoke detectors within the facility.

Findings include:

Document review on May 28, 2025, at 9:30 a.m., revealed documentation of smoke detector sensitivity testing was unavailable at time of survey.

Exit Interview with the Administrator on May 28, 2025, at 11:45 a.m., confirmed smoke detector sensitivity testing was not available at time of survey.

Plan of Correction - To be completed: 06/19/2025

The last smoke detector sensitivity testing was done at the center 4/24/24. The report is now on file in the building. The administrator understands this inspection is to be done every 2 years and will monitor and make sure all reports will be on file following the inspection.

28 Pa. Code § 569.2 STANDARD Subdivision of Building - Smoke Barrier:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5

Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations affecting two smoke compartments.

Findings include:

Observation on May 28, 2025, revealed unsealed penetrations of smoke barrier walls in the following locations:

a. 10:30 a.m., above smoke doors by D.O.N office, around blue data wire.
b. 10:50 a.m., above smoke doors to Pre-op, around blue data wires.

Exit Interview with the Administrator on May 28, 2025, at 11:45 a.m., confirmed the unsealed penetrations.

Plan of Correction - To be completed: 06/06/2025

Unsealed penetrations of smoke barrier walls above smoke doors of DON office and doors to PRE-OP area around blue data wiring were sealed with 3M Brand Fire Barrier CP-25WB+ chaulking. System No W-L-3001.(Formerly System No. 149). This was completed on June 6, 2025 by K2B HVAC SERVICE.

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 C 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:

Document review on May 28, 2025, at 9:30 a.m., revealed the facility lacked documentation indicating a four-year inspection of the fire/smoke fire dampers was performed.

Exit Interview with the Administrator on May 28, 2025, at 11:45 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 07/20/2025

The center was under the impression the damper inspection was due every 4 - 6 years. We understand now, for surgery centers, it is every 4 years. The last Damper inspection was 2020. Life Safety Services has been contacted (Keystone has always done it previously), a new contract has been signed and Life Safety will be calling the Administrator to set a date for inspection. The inspection will be within 30 days from today. This will now be monitored by the Administrator, reported to the Safety Committee, MAB and Governing Board.

28 Pa. Code § 569.2 STANDARD Electrical Systems -Essential Electric System:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generators, affecting one generator.

Findings Include:

Document review on May 28, 2025, at 9:30 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items:

a. weekly battery voltage.
b. annual fuel quality report.

Exit Interview with the Administrator on May 28, 2025, at 11:45 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 07/31/2025

A weekly battery voltage log will be monitored by the Administrator and or 2 RNs when the administrator is not available. This was started on May 19th, 2025.

The annual fuel quality was performed on 5/17/2025. The results are expected in 6-8 weeks. As of today, 6/18/2025, it is not in yet. The administrator will check daily for report and make sure the yearly maintenance along with the quarterly inspections are done and monitored in the Generator logbook.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement