Pennsylvania Department of Health
JEFFERSON SURGICAL CENTER AT THE NAVY YARD
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.

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JEFFERSON SURGICAL CENTER AT THE NAVY YARD - 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 14, 2023, at Jefferson Surgical Center At the Navy Yard, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.

Plan of Correction:

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

Facility ID# 22511501
Component 01

Based on a Revisit to a Recertification/Relicensure Survey completed on February 14, 2023, it was determined that Jefferson Surgical Center At the Navy Yard 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 four-story, Type II (000) unprotected non-combustible construction, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to maintain accurate floor plans outlining designated rated partitions, affecting one floor plan.

Findings Include:

1. Observation on February 14, 2023, at 10:30 am, revealed the provided floor plans did not indicate a continuous tenant separation wall between the ASC and the common corridor.

Interview at the exit conference with the Administrator and Maintenance Director on
February 14, 2023, at 12:00 pm, confirmed the missing floor plan wall designation.

**************************

Observation during onsite Revisit conducted on May 3, 2023, between 10:30 am and 11:00 am, revealed the following:

Item 1. Not Completed. Floor plans were not updated to indicate continous tenant separation wall.

Exit interview with the Administrator on May 3, 2023, at 11:00 am, confirmed the missing floor plan update.

Plan of Correction - To be completed: 08/15/2023

1. The facility is currently reviewing onsite H drawings, and working with an architect to update the life safety plans to reflect a continuous tenant separation wall between the ASC and the common corridor.

We have been in contact with Bill Gutches from the Plan Review Department and are submitting documents for his review and approval.

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