Pennsylvania Department of Health
WATERFRONT SURGERY CENTER, LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WATERFRONT SURGERY CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID# 16601501
Component 01
Waterfront Medical Center, Suite 110, 1st floor.

Based on a Relicensure Survey completed on February 8, 2024, it was determined that Waterfront Surgery 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 II (000), unprotected non-combustible building, without a basement, that is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform one of four required fire drills.

Findings include:

1. Review of documentation on February 8, 2024, at 8:30 a.m., revealed the facility lacked documentation for the fourth quarter fire drill.

Interview with the Facility Maintenance Director on February 8, 2024, at 8:30 a.m., confirmed the facility lacked documentation for a drill between October and December in 2023.

Plan of Correction - To be completed: 02/15/2024

The Director of Nursing/Designee will monitor completion of required quarterly fire drills by documenting completion of required drills on the Emergency Drill Log Sheet located in the front of the EMERGENCY DRILL BINDER.

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