Pennsylvania Department of Health
JEFFERSON ENDOSCOPY CENTER AT BALA
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 15 surveys for this facility. Please select a date to view the survey results.

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JEFFERSON ENDOSCOPY CENTER AT BALA - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: JEFFERSON ENDOSCOPY CENTER AT BALA LLC - Component: 01 - Tag: 0000

Facility ID# 24431501
Component 01

Based on a Relicensure Survey completed on February 27, 2025, it was determined that Jefferson Endoscopy Center At Bala, LLC 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 non-combustible building, that is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Electrical Systems -Essential Electric System:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: JEFFERSON ENDOSCOPY CENTER AT BALA LLC - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed maintain and inspect the emergency generator, affecting the entire facility.
Findings include:
Document Review on February 27, 2025, between 9:00 a.m. and 12:00 p.m., revealed the facility failed to provide documentation of the annual fuel quality test.
Exit interview with the Administrator on February 27,2025, at 12:00 p.m., confirmed the lack of documentation.

Plan of Correction - To be completed: 03/16/2025

The administrator contacted the contracted emergency generator servicing provider and scheduled a fuel analysis immediately after survey. This analysis was performed on 3/1/2025 and the center is awaiting the final report.

To prevent future emergency generator deficiencies, the administrator will be responsible to reach out to vendor for analysis to ensure compliance of testing on an annual basis. An annual fuel analysis has been placed in the yearly inspection agreement between vendor and administrator.

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