Pennsylvania Department of Health
SALLY K. BALIN AMBULATORY SURGICAL CENTER, P.C.
Building Inspection Results

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SALLY K. BALIN AMBULATORY SURGICAL CENTER, P.C.
Inspection Results For:

There are  24 surveys for this facility. Please select a date to view the survey results.

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SALLY K. BALIN AMBULATORY SURGICAL CENTER, P.C. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: CLASS C ASF - Component: 01 - Tag: 0000


Facility ID# 09421500
Component 01

Based on a Relicensure Survey completed on May 17, 2023, it was determined that Sally K. Balin Ambulatory Surgical Center, P.C. 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 III (200), unprotected ordinary construction, with a basement, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.



 Plan of Correction:


28 Pa. Code 569.2 STANDARD Sprinkler System - Maintenance and Testing:State only Deficiency.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0353

Based on observation, document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting two of three levels.

Findings include:

1. Document review on May 17, 2023, at 9:55 am, revealed the facility could not produce documentation showing quarterly sprinkler inspections had been performed for the 3rd quarter of 2022.

Exit Interview with the Administrator and Project Supervisor on May 17, 2023, at 11:10 am, confirmed the missing documentation.


2. Observation on May 17, 2023, at 10:15 am, revealed in OR-1 closet, items were stored directly under and within 18 inches of the sprinkler.

Exit Interview with the Administrator and Project Supervisor on May 17, 2023, at 11:10 am, confirmed the obstructed sprinkler.






 Plan of Correction - To be completed: 05/18/2023

1. As part of our Plan of Correction our Facility has a contract with Common Wealth Fire Protection to perform our quarterly sprinkler inspections. They were unable to satisfy their requirements of the contract for one quarter in 2022. Common Wealth Fire Protection had preemptively performed the third quarter of 2022 inspection still within the second quarter which led to the deficient gap that was found in services. They have since performed inspections for the fourth quarter December 2022, and first quarter March 2023. Moving forward, Common Wealth Fire Protection is to be called for appointments each quarter by the building manager and or Administrator to confirm for quarterly inspection by Common Wealth Fire Protection to perform the quarterly sprinkler inspections within the required time period, sign off on the paperwork after the inspection is performed, and report the findings to the Governing Body each quarter.

2.As part of our Plan of Correction at our Facility the items that were observed during the inspection within 18 inches of the sprinkler were immediately removed and reallocated. To ensure the deficiency will not occur a sign was placed to remind staff to not store items within 18" of the closet sprinkler. The staff was in serviced on the directive an 18 inch clearance from sprinkler heads be maintained and to notify the building manager or administrator if deficiencies were found to be corrected. An audit will be conducted the storage closet in OR 1 weekly 4 times then monthly 3 times by the building manager to ensure ongoing compliance. The results of the audit observations will be reported, reviewed and trended results will be reported to the Governing Body for further recommendations.
28 Pa. Code 569.2 STANDARD Gas Equipment -Cylinder and Container Storage:State only Deficiency.
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0923
Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of two floors.

Findings include:

1. Observation on May 17, 2023, at 10:30 am, revealed 2- freestanding oxygen cylinders in the lower-level oxygen storage room #132.

Exit Interview with the Administrator and Project Supervisor on May 17, 2023, at 11:10 am, confirmed the unsecured oxygen cylinders.



 Plan of Correction - To be completed: 06/01/2023

As part of our Plan of Correction at our Facility the oxygen cylinders were immediately placed in appropriate storage rack or chained. As a deficiency was found the administrator and building manager will review and evaluate the cylinder storage for room #132. In prevention of this reoccurrence the facility contracted services to provide a quantity of more secured oxygen cylinder storage to provide ample storage for cylinders. This project was completed on June 1, 2023. Also to prevent this from reoccurring the Administrator and Building manager will educate the staff and provide in service on maintaining proper oxygen storage. The staff will be told to notify the building manager or administrator if deficiencies were found to be corrected. An audit will be conducted the Room #132 weekly 4 times then monthly 3 times by the building manager to ensure ongoing compliance. The results of the audit observations will be reported, reviewed and trended results will be reported to the Governing Body for any further recommendations.

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