Nursing Investigation Results -

Pennsylvania Department of Health
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  19 surveys for this facility. Please select a date to view the survey results.

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MID-ATLANTIC GASTROINTESTINAL CENTER II - 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 February 5, 2019, at Mid-Atlantic Gastrointestinal Center II, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.

 Plan of Correction:

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

Facility ID# 21591501
Component 01
Endoscopy Center

Based on a Recertification/Relicensure Survey completed on February 5, 2019, it was determined that Mid-Atlantic Gastrointestinal Center II was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).

This is a one-story, Type V (000), unprotected wood frame structure, with a basement, which is fully sprinklered.

 Plan of Correction:

NFPA 101 STANDARD Fire Drills:Not Assigned
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and 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. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. through
Name: MAIN BUILDING - Component: 01 - Tag: 0712

Based on document review and interview, it was determined the facility failed to perform fire drills, as required for the component.

Findings include:

1. Review of documentation on February 5, 2019, between 10:15 AM and 11:15 AM revealed the facility did not perform required fire drill, during the 3rd Quarter.

Interview with the Center Director on February 5, 2019, at 11:15 AM confirmed the 3rd Quarter fire drill was not conducted.

 Plan of Correction - To be completed: 02/18/2019


Fire drills will be held at unexpected times under varying conditions, at least quarterly on each shift and include transmission of the fire alarm and participation from all staff in attendance.
The Center Leader will establish a schedule for all quarterly fire drills in the Leadership calendar and ensure fire drills are performed each quarter.
Fire drills will be documented on the `Fire Drill Report' and include all present teammates. An evaluation will completed to determine if any change in the procedure is needed. .
The Center Leader is responsible for ensuring the occurrence of quarterly fire drills. The Center Leader or designee will review each completed fire drill report to ensure fire drills are occurring each quarter and times of occurrences remain varied from quarter to quarter. Fire Drill reports will be maintained the Environment of Care notebook behind the Fire Drill tab for ease in locating and tracking for quarterly occurrences. The Center Leader will provide the report and the evaluation of the drill to the QAPI Committee quarterly for review and recommendations. Recommendations will be submitted to the Governing Body for review and approval.

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