Pennsylvania Department of Health
ST. LUKE'S ENDOSCOPY CENTER - BUXMONT
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 19 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.


ST. LUKE'S ENDOSCOPY CENTER - BUXMONT - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID# 21561501
Component 01
Main Building

Based on a Relicensure Survey completed on March 13, 2024, it was determined that St. Luke's Endoscopy Center - Buxmont 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 V (000), unprotected wood frame construction, which is fully sprinklered.

Approved as a Class B Ambulatory Surgical Facility.

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 B ASF - Component: 01 - Tag: 0211

Based on observation, document review and interview, it was determined the facility failed to maintain the means of egress free of impediments and ensure fire door assemblies meet code, affecting the entire facility.

Findings Include:

1. Observation made on March 13, 2024, revealed the front exit door had a thumb-lock installed. The locking device was not readily distinguishable when it is locked.

Exit Interview with the Facility Administrator and the Director of Plant Operations on March 13, 2024, confirmed a locking mechanism was installed.

2. Documentation reviewed on March 13, 2024, revealed 5 of 5 noncompliant fire door deficiencies on the inspection report dated March 10, 2022. State approved plans do not show fire rated door assemblies, yet there are rated door frames and hardware within the facility.

Exit Interview with the Facility Administrator and the Director of Plant Operations on March 13, 2024, confirmed fire rated door components were installed.

Plan of Correction - To be completed: 03/25/2024

Response:
1. Company owner from Legacy Doors is scheduled to review the thumb-lock of front entrance door 3/26/2024. Will recommend and then install mechanism to indicate Opened vs Locked. Project will be completed by 4/30/2024.

2. Company owner from Legacy Doors is scheduled to review current door assemblies and door frames 3/26/2024.
Medical architect employed by St. Luke's was consulted 3/22/2024. Confirmed that there have not been any changes to doors, door frames, nor door assemblies as compared to the 2007 DOH-approved original blueprints.

28 Pa. Code § 569.2 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7

Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain smoke resistive separation of hazardous areas, affecting 1 location within the compartment.

Findings Include:

Observation made on March 13, 2024, revealed there was storage, including boxes, housed within the ambulance entrance vestibule.

Exit Interview with the Facility Administrator and the Director of Plant Operations on March 13, 2024, confirmed the contents creating a hazardous area.

Plan of Correction - To be completed: 03/25/2024

Response: Pt Care Manager will speak with individual who places weekly order and request personal review to determine if hazardous item has been ordered. Weekly appointments will be noted on Outlook calendar. Pt care manager will be notified by endoscopy staff when orders have arrived inside the building and will assure the item(s) is placed in a proper location immediately upon arrival.

28 Pa. Code § 569.2 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5

Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0345
Based on document review and interview, it was determined the facility failed to maintain fire alarm components in operable condition, affecting 1 fire alarm device within the facility.

Findings Include:

Documentation reviewed on March 13, 2024, revealed the fire alarm report dated September 5, 2023 indicated a duct detector was not inspected due to inaccessibility. Confirmation of inspection was not available at the time of survey.

Exit Interview with the Facility Administrator and the Director of Plant Operations on March 13, 2024, confirmed the fire alarm component was not inspected/tested.

Plan of Correction - To be completed: 03/25/2024

Response: Patient Care Manager responsible to review all reports received by outside vendors regarding Fire Safety checks. Pt Care Manager will request all reports be delivered via email format using work email address.
If an item is missing, the Patient Care Manager will speak with the head of the vendor's department to require a full inspection be completed within 48 hrs. If there is no response, patient care manager will consult with the Operations Manager of St. Luke's Upper Bucks campus (Buxmont's liaison) to determine an alternate vendor to complete the required work.

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: CLASS B ASF - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to maintain proper testing of alarm components during fire drills, affecting 4 of four drills.

Findings Include:

Documentation reviewed on March 13, 2024, revealed alarm devices were not utilized to activate the fire alarm system during fire drills.

Exit Interview with the Facility Administrator and the Director of Plant Operations on March 13, 2024, confirmed alarm devices were not utilized.

Plan of Correction - To be completed: 03/25/2024

Response: Patient Care Mgt will modify fire drills and incorporate fire pulls (varying the pull each quarter). Fire drill evaluation form revised.

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

Gas and Vacuum Piped Systems - Warning Systems
All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable.
5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0904

Based on document review and interview, it was determined the facility failed to maintain proper operation of medical gas components, affecting 1 of two alarm panels.

Findings Include:

Documentation reviewed on March 13, 2024, revealed the Medical Gas Report dated 1/24 - 12/24 indicated the medical gas alarm panel will not alarm. The panel is located at the front receptionist desk.

Exit Interview with the Facility Administrator and the Director of Plant Operations on March 13, 2024, confirmed the medical gas component was not operating properly.

Plan of Correction - To be completed: 04/30/2024

Response: In consultation with Medigas vendor, Buxmont's Governing Board approved the removal of the panel in the Reception area (main panel will remain in current location- nurse's desk area in Endoscopy; visible and audible alarms are continuous until button is pushed to silence; flashing alarm remains visible until issue checked and alarm "reset"). Work will be completed by 4/30/3024. Decision was made based on 2 regulations:
a) Buxmont is considered a Category #2 facility (using 4.1 with 4.1.1 and 4.1.2 definitions).

3/27/2024 POC completion date revised to 04/30/2024.
b) Warning Systems' regulation 5.2.9 will be followed leaving 1 alarm panel that is already established and possessing the following criteria:
1) Located in an area of continuous surveillance while the facility is in operation (panel at nurse's desk area which is opened and includes admissions and recovery areas; Clinical Coordinator (DON) is in attendance).
2) Pressure and vacuum switches/sensors are mounted at the source equipment with a pressure indicator at the master alarm panel.

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