Pennsylvania Department of Health
PREMIER AT EXTON SURGERY CENTER LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 11 surveys for this facility. Please select a date to view the survey results.

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PREMIER AT EXTON SURGERY CENTER LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: 00 - Tag: 0000
Based on an Emergency Preparedness Survey completed on May 22, 2024, at Premier at Exton Surgery Center Llc, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.

Plan of Correction:

Initial comments:Name: PREMIER AT EXTON SURGERY CENTER, LLC - Component: 01 - Tag: 0000
Facility ID 24531501

Component 01

Main Building

Based on a Recertification/Relicensure Survey completed on May 22, 2024, it was determined that Premier at Exton Surgery Center Llc, 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 three-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 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: PREMIER AT EXTON SURGERY CENTER, LLC - Component: 01 - Tag: 0131
Based on observation and interview, it was determined the facility failed to maintain the positive latching of doors within building separating common walls, affecting the entire component.
Findings include:

Observation on May 22, 2024, at 11:33 AM, revealed the Lobby door to Suite 100 failed to positively latch within the door frame.Interview with the Administrator on May 22, 2024, at 11:33 AM, confirmed the door did not latch within the frame.

Plan of Correction - To be completed: 06/10/2024

Administrator will contact fire door repair company who just repaired the door jamb to correct the latching issue by 6/10/2024.
Door latching will be added to the monthly Environment of Care (EOC) checklist for ongoing assessment. Any unlatching doors will be reported to the Administrator who will call the door repair company.

EOC reports will be reviewed at quarterly QUAPI meetings and reported to the governing body.

Waiting room door will be repaired by 6/30/2024.

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