Pennsylvania Department of Health
EINSTEIN MEDICAL CENTER MONTGOMERY SHORT PROCEDURE UNIT
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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.


EINSTEIN MEDICAL CENTER MONTGOMERY SHORT PROCEDURE UNIT - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

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

Facility ID# 23671501
Component 01

Based on a Relicensure Survey completed on September 27, 2023, it was determined Einstein Medical Center Montgomery Short Procedure Unit was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a two-story, Type II (000), unprotected, noncombustible construction, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Multiple Occupancies:

Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44

Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain tenant separation walls, affecting one tenant separation wall.

Findings include:

1. Observation on September 27, 2023, at 10:00 am, revealed above patient discharge door, unsealed penetrations around MC wire and a drilled hole.

Interview at the exit conference with the Director of Quality and Maintenance Director on September 27, 2023, at 10:30 am, confirmed the penetrations.

Plan of Correction - To be completed: 10/13/2023

The noted penetration will be sealed using high-performance intumescent fire stop sealant - Hilti FS-One #2101531. In addition, the following approved through penetration fire stop system will be used in the location and is kept on file by the Director of Facilities: Hilti System No. C-AJ-8044

Completion Date:
October 23, 2023

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

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0353

Based on document review and interview, it was determined the facility failed to ensure automatic sprinkler components were maintained, affecting one sprinkler system.

Findings Include:

1. Document review on September 27, 2023, at 9:30 am, revealed current 5-year internal sprinkler inspection was not available for review at time of survey.

Interview at the exit conference with the Director of Quality and Maintenance Director on September 27, 2023, at 10:30 am, confirmed the missing documentation.

Plan of Correction - To be completed: 10/13/2023

The 5-year internal sprinkler inspection was scheduled and completed on October 6. 2023. Final report is pending. Any recommended follow-up actions noted in the final report will be addressed in a timely manner.

Completion Date:
October 6, 2023

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

Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0907

Based on documentation review and interview, it was determined the facility failed to maintain the medical gas system, affecting one medical gas system.

Findings include:

1. Document review on September 27, 2023, at 9:20 am, revealed the following deficiencies listed on the September 22, 2023, Medical Gas Report. Corrective action was not available at time of survey.

a. Right side primary regulator is not adjusting and drifting towards pressure relief setting;
b. Vacuum pump replacement required for the coupling inserts, intake filters and gear oil.

Interview at the exit conference with the Director of Quality and Maintenance Director on September 27, 2023, at 10:30 am, confirmed the medical gas deficiencies.

Plan of Correction - To be completed: 10/13/2023

The required repairs have been scheduled with the vendor and will be completed on October 16, 2023.

Completion Date:
October 16, 2023

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