Pennsylvania Department of Health
ORTHOPAEDIC SURGERY CENTER AT BRYN MAWR HOSPITAL
Building Inspection Results

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ORTHOPAEDIC SURGERY CENTER AT BRYN MAWR HOSPITAL
Inspection Results For:

There are  9 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.
ORTHOPAEDIC SURGERY CENTER AT BRYN MAWR HOSPITAL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on April 9, 2024, at Orthopaedic Surgery Center at Bryn Mawr Hospital, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.





 Plan of Correction:


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


Facility ID# 24551501
Component 01
Main Building

Based on a Recertification/Relicensure Survey completed on April 9, 2024, it was determined that Orthopaedic Surgery Center at Bryn Mawr Hospital 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 four-story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.






 Plan of Correction:


NFPA 101 STANDARD Electrical Systems - Other:Not Assigned
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)





Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of four levels.

Findings include:

Observation on April 9, 2024, at 11:00 a.m., revealed on the fourth floor, in Sterile Processing Room, a ceiling mounted receptacle was detached from its housing, exposing the inner wiring.

Exit Interview with the Administrator and Regional Director on April 9, 2024, at 12:00 p.m., confirmed the exposed wiring.

Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.






 Plan of Correction - To be completed: 04/09/2024

Upon identifying the issue, we had the facility engineer install a spreader bar above the ceiling that secured the outlet to the junction box providing more stability for the outlet. During our monthly rounding, the outlet will be inspected to ensure it is secure within its housing. All deficiencies identified during rounding will be reported to the administrator/designee and reported at the facility EOC/Patient Safety Committee on a quarterly basis.
NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:Not Assigned
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the improper use of electrical devices, affecting one of four levels.

Findings include:

Observation on April 9, 2024, at 11:30 a.m., revealed a surge protector was plugged into another surge protector and powering equipment, on the fourth floor, Data Room.

Exit Interview with the Administrator and Regional Director on April 9, 2024, at 12:00 p.m., confirmed the unauthorized electrical device.







 Plan of Correction - To be completed: 04/15/2024

While touring the facility, we found a surge protector daisy chained to another surge protector in the data room. After identifying the devices attached to the surge protector, we were able to remove them, plug them into the wall, and eliminate one of the surge protectors from the space. Notification was made to the Director of Information Services, so she could inform her staff of the deficiency and reinforce this does not happen in the future. During monthly Environment of Care rounding, we will inspect all areas to make sure there is no daisy chaining of devices. During monthly staff meetings, the administrator will reinforce this with the entire team to prevent any future occurrences. Any future deficiencies relating to this matter will be reported to the administrator, and on a quarterly basis addressed at the facility EOC/Patient Safety Committee.

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