Nursing Investigation Results -

Pennsylvania Department of Health
ERIE AMBULATORY SURGERY CENTER
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ERIE AMBULATORY SURGERY CENTER
Inspection Results For:

There are  18 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.
ERIE AMBULATORY SURGERY CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID # 23661501
Component 01
Main Building

Based on a Relicensure Survey completed on February 6, 2020, it was determined that Erie Ambulatory Surgery Center, 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 two-story, Type II (222), fire resistive building, with a basement and a roof level mechanical room, that is fully sprinklered.







 Plan of Correction:


28 Pa. Code 569.2 STANDARD Exit Signage:State only Deficiency.
Exit Signage
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
20.2.10, 21.2.10, 7.10
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0293

Based on document review and interview, the facility failed to maintain exit signage requirements throughout the facility.

Findings include:

1. Document review on February 6, 2020, at 10:00 a.m., revealed the facility lacked documentation to indicate the emergency lighting deficiences noted were corrected and inspected at the time of the survey. (Last inspection was documented January 2019).

Interview with the maintenance leader and administrator on February 6, 2020, at 10:00 a.m., confirmed the above emergency lighting documentation was not available at the time of the survey.







 Plan of Correction - To be completed: 02/17/2020

The last monthly inspection of emergency lighting that was reviewed at the time of February 6, 2020 survey was January 12, 2020, not January 2019 as noted in the surveyor report.

Ballasts were ordered on February 6, 2020, and are on backorder at the warehouse. Installation is to be completed on February 21, 2020 to correct the emergency lighting deficiencies. This completed work will be documented in the work order system. Emergency lighting ballasts are typically kept in stock at the center, although the backorder affected the available stock.

The applicable policy related to emergency lighting inspections/testings was reviewed, with no revisions required.

Any areas of concern related to emergency lighting discovered during routine Maintenance rounds, as well as monthly inspections/testing, are addressed. All deficiencies and corrective work is required to be documented. Documentation of all inspections, testing and maintenance related to emergency lighting is maintained in the Manager of Maintenance office.

The Manager of Maintenance is responsible for ensuring the monitoring, completion and results of all inspections, testing and maintenance of emergency lighting.

The results of the inspections, testing and maintenance of all emergency lighting will continue to be reported at the quarterly ASC EOC/LS/EM Committee. The next meeting is scheduled for February 12, 2020.

28 Pa. Code 569.2 STANDARD Fire Alarm System - Testing and Maintenance:State only Deficiency.
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: MAIN BUILDING - Component: 01 - Tag: 0345

Based on observation and interview, the facility failed to maintain the fire alarm system for one of one system.

Findings include:

1. Observation on February 6, 2020, at 11:20 a.m., revealed the fire alarm panel listed one trouble signal.

Interview with the maintenance leader on February 6, 2020, at 11:20 a.m., confirmed the fire alarm was not in "normal" status.





 Plan of Correction - To be completed: 02/17/2020

The fire alarm system vendor replaced a failed duct detector on February 13, 2020. This duct detector was successfully tested after installation. With replacement of the failed duct detector, all signals on the fire alarm panel are back to "normal" status. This completed work was documented in the work order system.

The two applicable policies related to the fire alarm system, in accordance with NFPA 70 and NFPA 72, were reviewed, with no revisions required.

Any areas of concern related to the fire alarm system discovered during routine Maintenance rounds, as well as inspections/testing, are addressed. All deficiencies and corrective work is required to be documented. Documentation of all inspections, testing and maintenance related to the fire alarm system is maintained in the Manager of Maintenance office.

The Manager of Maintenance is responsible for ensuring the monitoring, completion and results of all inspections, testing and maintenance of the fire alarm system.

The results of the inspections, testing and maintenance of the fire alarm system will continue to be reported at the quarterly ASC EOC/LS/EM Committee. The next meeting is scheduled for February 12, 2020.

28 Pa. Code 569.2 STANDARD Portable Fire Extinguishers:State only Deficiency.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0355

Based on document review and interview, the facility failed to maintain fire extinguisher service tech certification, for one of one service techs.

Findings include:

Document review on February 6, 2020, at 10:10 a.m., revealed the fire extinguisher service tech certification expired in 2018.

Interview with maintenance leader and administrator on February 6, 2020, at 10:10 a.m., confirmed the fire extinguisher service tech certification expired in 2018.






 Plan of Correction - To be completed: 02/17/2020

The valid NFPA certification certificate for the one of one fire extinguisher technician was received on February 10, 2020. This certificate is maintained in the Manager of Maintenance office.

The applicable policy related to fire extinguishers, in accordance with NFPA 10, was reviewed, with no revisions required.

Any areas of concern related to the fire extinguishers discovered during routine Maintenance rounds, as well as inspections/testing, are addressed. All deficiencies and corrective work is required to be documented. Documentation of all inspections, testing and maintenance related to fire extinguishers is maintained in the Manager of Maintenance office.

The Manager of Maintenance is responsible for ensuring the monitoring, completion and results of all inspections, testing and maintenance of fire extinguishers.

The results of the inspections, testing and maintenance of fire extinguishers will continue to be reported at the quarterly ASC EOC/LS/EM Committee. The next meeting is scheduled for February 12, 2020.


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