Pennsylvania Department of Health
PHOENIXVILLE HOSPITAL AMBULATORY SURGERY CENTER – LIMERICK
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 23 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.


PHOENIXVILLE HOSPITAL AMBULATORY SURGERY CENTER – LIMERICK - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID# 15941501
Component 01
Main Building

Based on a Revisit to a Relicensure Survey completed on May 15, 2024, it was determined that Phoenixville Hospital Ambulatory Surgery Center - Limerick was not in substantial compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a two-story, Type II (111), protected non-combustible building, that is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Means of Egress - General:

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1

Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0211

Based on documentation review and interview, it was determined the facility failed to maintain fire rated door openings, affecting one of two levels.

Findings include:

Document review on May 15, 2024, at 9:30 a.m., revealed the July 2023, Annual Fire Door Inspection report listed 24- fire doors as deficient, evidence of corrective action was not available at the time of survey.

Exit Interview with the Administrator and Facilities Manager on May 15, 2024, at 11:00 a.m., confirmed the rated door deficiencies.

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Based on document review and interview during an offsite revist conducted on September 19, 2024 it was determined:

Not completed. The Annual Fire Door Inspection report listed 24- fire doors as deficient, evidence of corrective action was not available at the time of survey. 13 of the 24 fire doors have been corrected.

Exit interview with the Facilities Manager and Maintenance director on September 19, 2024 at 10:30am confirmed the remaining door deficiencies.

Plan of Correction - To be completed: 12/14/2024

ILSMs have been implemented for all failed doors.
Two doors require frame labeling which will be completed by 10/04/24. Three doors require replacement. These three doors are ordered and expected to be replaced by 12/14/24. All other doors have been repaired.
Doors will be inspected by a qualified person before ILSMs are removed.
Monthly fire door inspections will be conducted for a period of 6 months of 100% compliance and then annually by a qualified person.
Deficiencies and corrective actions will be reported annually to the EOC Committee.

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