Pennsylvania Department of Health
UPMC SURGERY CENTER
Building Inspection Results

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UPMC SURGERY CENTER
Inspection Results For:

There are  17 surveys for this facility. Please select a date to view the survey results.

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UPMC SURGERY CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN - Component: 01 - Tag: 0000


Facility ID #21961501
Component 01
Main Building

Based on a Relicensure Survey completed on March 29, 2023, it was determined that UPMC Surgery Center 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 II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.




 Plan of Correction:


28 Pa. Code § 569.2 STANDARD Hazardous Areas - Enclosure:State only Deficiency.
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: MAIN - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area doors, to be within the allowed gap margins, in one of two smoke zones within the component.

Findings include:

1. Observation on March 29, 2023, between 11:30 AM and 12:25 PM, revealed hazardous area doors exceeded minimum gap margins, at the following locations:

a. 11:30 AM, Receiving Room door #1084, top exceeded 1/8 inch;
b. 11:35 AM, Soiled Utility Room door #1082, top exceeded 1/8 inch;
c. 12:25 PM, Soiled Holding Room door #1047, top exceeded 1/8 inch.

Interview at the time of the exit conference with the President, Director of Operations, Assistant Director of Facilities Maintenance, Director Regulatory and Accreditation and Maintenance Electrician on March 29, 2023, at 1:15 PM, confirmed hazardous area doors exceeded the allowed gap margins.



 Plan of Correction - To be completed: 04/07/2023

The Fire Door gap solution ordered on 3/31/23 with an updated anticipated delivery date of 4/12/23. The solution will be installed as soon as the parts are received.

After installation of the fire door solution, the fire doors will be inspected monthly X3 months or until 100% compliance for 3 consecutive months is achieved.

The results of the inspections will be reported to the Environment of Care Committee monthly until the action plan is complete.
28 Pa. Code § 569.2 STANDARD Electrical Systems - Maintenance and Testing:State only Deficiency.
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Name: MAIN - Component: 01 - Tag: 0914

Based on document review and interview, it was determined the facility failed to provide documentation, verifying annual inspections of electrical receptacles, in resident care areas, in two of two smoke zones within the component.

Findings include:

1. Review of documentation on March 29, 2023, between 9:15 AM and 10:40 AM, revealed the facility lacked documentation, verifying electrical receptacles were tested, in the last 12 months.

Interview at the time of the exit conference with the President, Director of Operations, Assistant Director of Facilities Maintenance, Director Regulatory and Accreditation and Maintenance Electrician on March 29, 2023, at 1:15 PM, confirmed the lack of annual electrical inspection documentation.



 Plan of Correction - To be completed: 04/07/2023

The entire inventory of receptacles at the UPMC Surgery Center were tested on 4/3/23 with appropriate actions taken.

Going forward, receptacle testing for the Surgery Center has been entered into the electronic CMS Facilities Workorder System to generate an annual task. Facilities will generate a workorder for all failed receptacles. The completed receptacle testing report will be filed in the Surgery Center Life Safety Binder. Results of the annual inspection will be reported annually at the Environment of Care Committee meeting.


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