Pennsylvania Department of Health
VILLAGE SURGICENTER OF ERIE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 36 surveys for this facility. Please select a date to view the survey results.

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VILLAGE SURGICENTER OF ERIE - 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 June 6, 2024, it was determined that Village Surgicenter of Erie was not in compliance with the requirements of 42 CFR 416.54.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on June 6, 2024, at 1:47 p.m., revealed the facility lacked an emergency preparedness plan review date within the last two years.

Interview with the clinical director on June 6, 2024, at 1:47 p.m., confirmed the emergency preparedness plan did not include a recent review date.

Plan of Correction - To be completed: 06/17/2024

Emergency Preparedness Plan was updated to contain all required documents Reviewed and signed by staff. Will be presented at Medical Advisory Board for approval at September 2024 meeting. Will be forwarded to Governing Board for final approval. Will be reviewed yearly by staff with their mandatory yearly educational requirements. Updated every 2 years for content.

403.748(d), 416.54(d), 418.113(d), 441.184(d), 482.15(d), 483.475(d), 483.73(d), 484.102(d), 485.542(d), 485.625(d), 485.68(d), 485.727(d), 485.920(d), 486.360(d), 491.12(d), 494.62(d) STANDARD EP Training and Testing:

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.

Observations:
Name: - Component: -- - Tag: 0036

Based on document review and interview, the facility failed to maintain emergency preparedness guidelines for one of one emergency preparedness plan.

Findings include:

Document review on June 6, 2024, at 1:52 p.m., revealed the facility was unable to provide staff training and testing documentation for site-specific policies and procedures outlined in the emergency prepardness plan.

Interview with the clinical director on June 6, 2024, at 1:52 p.m., confirmed the emergency preparedness plan did not include the documentation.

Plan of Correction - To be completed: 06/17/2024

Employee Education: Emergency Management Plan Receipt and Acknowledgment From contain the following:

1. I have received the Surgery Policies: "Emergency Preparedness" "Emergency Management Plan"

2. I understand and agree to follow these Surgery Partners Policies and understand that compliance with these policies is required as a condition of employment.

3. I was given the opportunity to ask questions.

This will be monitored with employees yearly educational requirement. This has been completed by June 30,2024, then will be reviewed yearly.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #11001500
Component 01
Main Building

Based on a Recertification Survey completed on June 6, 2024, it was determined that Village Surgicenter of Erie 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.

Plan of Correction:

NFPA 101 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: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review, observation, and interview, the facility failed to meet emergency lighting maintenance and testing requirements.

Findings include:

1. Observation on June 6, 2024, between 12:50 p.m. and 1:40 p.m., revealed multiple OR rooms had emergency battery back-up lights in the ceiling. The lights did not illuminate when the test buttons were pressed.

Interview with the clinical director on June 6, 2024, at 1:40 p.m., confirmed the lights did not illuminate when tested.

2. Document review on June 6, 2024, at 10:40 a.m., revealed the last-documented annual 90-minute test occurred in February 2023.

Interview with the clinical director on June 6, 2024, at 10:40 a.m., confirmed the deficiency at the time of the survey.

Plan of Correction - To be completed: 06/17/2024

90-minute Emergency lighting was completed June 7, 2024.

Will be completed by June 7, 2025.

Emergency lighting in OR:

There are 2 sets of emergency lights in each OR. The first is a double bulb battery operated located by anesthesia. This checked monthly and yearly for 90 minutes. This is activated with power loss. The 2nd light is a single flush mounted ceiling light which is direct wire battery backup hooked to generator transfer switch. The transfer switch must be thrown to activate emergence light for testing. This was verified via our original electric contractor. It will test monthly with our under-load generator test.

Both sets of lights will be tested monthly during generator load test.

NFPA 101 STANDARD Alcohol Based Hand Rub Dispenser (ABHR):

Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
o Corridor is at least 6 feet wide.
o Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols.
o Dispensers shall have a minimum of 4-foot horizontal spacing.
o Not more than an aggregate of 10 gallons of fluid or 1135 ounces of aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room.
o Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30.
o Dispensers are not installed within 1 inch of an ignition source.
o If floor is carpeted, the building is fully sprinkler protected.
o ABHR does not exceed 95% alcohol.
o Operation of the dispenser shall comply with Section 20.3.2.6(11) or 21.3.2.6(11).
o ABHR is protected against inappropriate access.
21.3.2.6, 8.7.3.1, CFR 416.44

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0325

Based on document review and interview, the facility failed to meet alcohol-based hand rub dispenser requirements for one of one facility.

Findings include:

Observation on June 6, 2024, at 1:33 p.m., revealed alcohol-based hand rub dispensers were located within one inch of an ignition source in multiple locations throughout the facility.

Interview with the clinical director on June 6, 2024, at 1:33 p.m., confirmed the deficiencies.

Plan of Correction - To be completed: 06/17/2024

Tour of facility was completed by Clinical Director/Clinical Nurse Manager to determine how many hand sanitizers were in violation. Explored nonalcoholic hand sanitizers options for purchase. Upon receipt of nonalcoholic hand sanitizer, it will be placed in violated areas. The device will be labeled to ensure correct replacement in the future. Targeted completion by June 30, 2024.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review and interview, the facility failed to meet sprinkler system maintenance and testing requirements.

Findings include:

Document review on June 6, 2024, at 9:55 a.m., revealed multiple sprinkler reports (3-11-24, 12-8-23, 9-13-23, and 6-9-23) noted a leaking control valve. The facility was unable to provide corrective documentation for the deficiency.

Interview with the clinical director on June 6, 2024, at 9:55 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 06/17/2024

Reviewed report with Armor Construction. Provided a quote for repair Scheduled repair for water control valve 06/21/2024 at 0700.

Future inspection reports will be reviewed for critical and non-critical results.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on document review and interview, the facility failed to meet building subdivision space requirements for all fire/smoke dampers, affecting the entire facility.

Findings include:

Document review on June 6, 2024, at 10:07 a.m., revealed the facility failed to provide documentation for the fire/smoke damper inspection, which includes the locations of the dampers and if the dampers passed or failed inspection.

Reference: NFPA 80 19.3.4

Interview with the clinical director on June 6, 2024, at 10:07 a.m., confirmed the facility was unable to provide the documentation at the time of the survey.

Plan of Correction - To be completed: 06/20/2024

Contacted Scobell - mechanical vendor for inspection. Inspection scheduled 6-28-2024 with report to follow.

Will update log to include report of inspection every 5 years.

Patient care was not affected due to this deficiency, Future inspections will be completed on a scheduled basis.

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Inspection and:

Gas and Vacuum Piped Systems - Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

Plan of Correction - To be completed: 06/19/2024

contacted CHT regarding all deficiencies. Order placed for parts to repair deficiencies. CHT will contact Clinical nurse Manager when parts have arrived to arrange time for repair.

Yearly reports will be monitored by Clinical Director/Clinical Nurse Manager and any deficiencies will be reviewed and corrected.

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