Observations:
Name: JEFFERSON ENDOSCOPY CENTER AT BALA LLC - Component: 01 - Tag: 0907
Based on document review and interview, it was determined the facility failed to maintain the medical gas system, affecting one medical gas system.
Findings include:
Document review on February 14, 2024, at 9:30 a.m., revealed, the complete medical gas report for the current year was not available for review at time of survey.
Exit Interview with the Insurance Verifier on February 14, 2024, at 10:30 a.m., confirmed the missing documentation.
| | Plan of Correction - To be completed: 02/23/2024
The Administrator audited all facility building maintenance and Life Safety records for compliance and concluded prior to the DOH inspection, the annual Medical Gas Outlet inspection was not completed in 2023 and therefore the facility was out of compliance.
The Administrator contacted the vendor who holds the contract for such inspections and immediately scheduled the inspection date for the following week.
The Medical Gas Outlet inspection was completed on Friday 2/23/24 and the facility had no reported issues and successfully passed the inspection.
The Administrator will reach out to the Med Gas Outlet vendor to ensure the inspection is done on an annual basis to sustain compliance.
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