Pennsylvania Department of Health
HOLY REDEEMER AMBULATORY SURGERY CENTER LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 26 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.


HOLY REDEEMER AMBULATORY SURGERY CENTER LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING 01 (CLASS C) - Component: 01 - Tag: 0000

Facility ID# 11251500
Component 01

Based on a Relicensure Survey completed on April 11, 2024, it was determined that Holy Redeemer Ambulatory Surgical Center, LLC 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 building, with a basement, that is fully sprinklered.

Approved as 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: MAIN BUILDING 01 (CLASS C) - Component: 01 - Tag: 0291

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

Findings include:

Observation on April 11, 2024, at 9:45 a.m., revealed in the Lobby, the battery back-up lights by the main entrance, failed to illuminate when tested.

Exit Interview with the Administrator on April 11, 2024, at 11:00 a.m., confirmed the battery back-up light failed to illuminate when tested.

Plan of Correction - To be completed: 06/08/2024

The Battery light in the lobby was not on our inspection list as it is inspected by the building staff. We have added this light to our inventory and will test monthly and annually since it is in our path of egress We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this 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: MAIN BUILDING 01 (CLASS C) - 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 one of two levels.

Findings include:

Observation on April 11, 2024, at 10:20 a.m., revealed above the smoke doors by Men's Locker Room, an unsealed penetration around a data wires.

Exit Interview with the Administrator on April 11, 2024, at 11:00 a.m., confirmed the penetration.

Plan of Correction - To be completed: 06/08/2024

The penetration will be sealed with a UL approved through penetration fire stop system (Hilti Figure # W-L-1464) to maintain the 20 minute smoke resistance rating of the wall. Maintenance and IT installation staff will be re-educated on the proper procedure for sealing all fire/smoke rated penetrations and documented. Construction / renovation projects will be monitored on a continual basis for compliance also. Holy Redeemer Health System has implemented a Fire & Smoke Barrier Penetration Policy in 2012 that provides a comprehensive means of verifying that above ceiling work within Holy Redeemer Health System is accomplished in accordance with applicable building codes, standards, and related hospital policies. This policy applies to any work done in the buildings owned and or rented by the Holy Redeemer Health System. Permit forms are available in the Engineering & Maintenance office. All Smoke and Fire barriers will be inspected Quarterly for compliance as part of our preventative maintenance program and policy. The Director of Maintenance will be responsible for maintaining compliance of this inspection.

28 Pa. Code § 569.2 STANDARD Gas and Vacuum Piped Systems - Maintenance:

Observations:
Name: MAIN BUILDING 01 (CLASS C) - Component: 01 - Tag: 0907

Based on document review and interview, it was determined the facility failed to maintain the medical gas system, affecting one of one medical gas system.

Findings include:

Document review on April 11, 2024, at 9:00 a.m., revealed the March 7, 2024, Medical Gas Report indicated the following deficiency: " Coupling inserts require replacement " . Proof of corrective action was not available at time of survey.

Exit Interview with the Administrator on April 11, 2024, at 11:00 a.m., confirmed the medical gas deficiency.

Plan of Correction - To be completed: 06/08/2024

The replacement of the couplings referenced on the inspection sheet had been identified and service was scheduled but not completed prior to this inspection. The work has since been completed. Moving forward, we will be coordinating with our contractors to insure that any deficiencies identified are corrected within 30 days of identification. The Director of Maintenance will be responsible for maintaining compliance of this inspection.

28 Pa. Code § 569.2 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.

Observations:
Name: MAIN BUILDING 01 (CLASS C) - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of two levels.

Findings include:

Observation on April 11, 2024, at 10:15 a.m., revealed on the first floor, the Tele-Data Room wall switch was missing its cover plate, exposing the inner wiring.

Exit Interview with the Administrator on April 11, 2024, at 11:00 a.m., confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.

Plan of Correction - To be completed: 06/08/2024

The cover plate was replaced on the switch. We will monitor for these conditions during our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection

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