Pennsylvania Department of Health
FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER, LLC
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 4 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.


FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER - Component: 10 - Tag: 0000

Facility ID #24571501
Component 10
Fertility Partners of Pennsylvania Surgery Center

Based on a Relicensure Survey completed on May 22, 2024, it was determined that Fertility Partners of Pennsylvania Surgery Center was not in compliance with the following requirements of the Life Safety Code for a new ambulatory health care occupancy.

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

Plan of Correction:

NFPA 101 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: FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER - Component: 10 - Tag: 0353

Based on document review and interview, it was determined the facility failed to provide quarterly, annual, and 5-year maintenance documentation of the installed sprinkler system, which serves the entire component.

Findings include:

1. Review of documentation on May 22, 2024, between 9:45 AM and 9:50 AM, revealed the facility lacked documentation of the following tests and inspections:

a. 9:45 AM, wet system, annual main drain and control valves;
b. 9:48 AM, wet system, full year, four quarterly reports;
c. 9:50 AM, wet system, 5-year internal pipe/valve inspections.

Interview with the Administrator and Clinical Director on May 22, 2024, at 1:30 PM, confirmed the facility could not provide documentation of the required tests and maintenance of the installed sprinkler system.

Plan of Correction - To be completed: 07/10/2024

1. Premium Fire and Security, LLC is contracted by the Property Management of the building in which the Facility is located to perform testing and inspections for the fire alarm and sprinkler systems. The Facility Administrator coordinated with Premium Fire and Security, LLC, to provide the documentation of the annual sprinkler testing and inspection for the building including the Facility. It was confirmed by Premium Fire and Security that the annual sprinkler inspection was completed for the building and an outline of the inspection and dates performed were provided to the Facility Administrator.

a. Wet system, annual main drain and control valves – Inspection completed on 4/10/2024
b. Wet system, full year, four quarterly – Quarterly inspection not completed prior to 4/2024. The quarterly sprinkler inspection is scheduled to be completed no later than 7/10/2024.
c. Wet system, 5-year internal pipe/valve inspections – Due and Scheduled 7/9/2024

To ensure that annual and quarterly sprinkler system testing and inspections are completed and documented, the Facility Administrator will maintain an annual Building Safety Checklist. All testing and inspection activity will be recorded on the Building Safety Checklist upon completion and documentation of the testing and inspection will be kept in the Facility Building Safety binder.

The Facility Building Safety Checklist and Binder, which also contains inspection records for other elements of the building safety requirements, will be audited monthly by the Facility Administrator to ensure compliance. The audit will be conducted for a period of no less than 12 months. The audit will continue annually to ensure 100% compliance. Data will be reported to the Safety Committee on a quarterly basis.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10

Observations:
Name: FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER - Component: 10 - Tag: 0355

Based on document review and interview, it was determined the facility failed to document monthly owner's quick checks, and provide a certificate for the fire extinguisher technician, affecting the entire component.

Findings include:

1. Review of documentation on May 22, 2024, between 9:15 AM and 11:30 AM, revealed the facility lacked documentation the annual inspection had been completed by a Certified Fire Extinguisher Inspector.

Interview with the Administrator and Clinical Director on May 22, 2024, at 1:30 PM, confirmed the facility could not provide a certification for Fire Extinguisher Inspector.

2. Review of documentation on May 22, 2024, between 9:15 AM and 11:30 AM, revealed the facility lacked documentation verifying the fire extinguishers had been subjected to monthly owner's quick checks, throughout the component.

Interview with the Administrator and Clinical Director on May 22, 2024, at 1:30 PM, confirmed the facility could not provide documentation of owner's quick checks.

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

1. A request has been made to Premium Fire & Safety, LLC to provide a copy of the certification for the Inspector who completed the annual fire extinguisher inspection on 4/24/2024. A copy of the certification has been received by the Facility Administrator and has been placed on file. To ensure that the annual fire extinguisher inspection is completed and that the certification documentation for the fire extinguisher inspector is received with the inspection, the Facility Administrator will maintain a checklist to be reviewed upon completion of the annual inspection. The checklist, which will also contain inspection records of other elements for the building safety requirements, will be reviewed monthly to ensure compliance.

2. 2. The Facility maintains a monthly safety checklist for visual inspection of fire and safety components. The Monthly Safety Checklist has been updated to include the fire extinguishers located throughout the Facility. The designated staff member will complete a walkthrough of the Facility no later than the 15th of each month. Utilizing the Monthly Safety Checklist, the staff member will visually inspect all components as listed. Once the visual inspection is completed, the designated staff member will sign off on the extinguisher card attached to the fire extinguisher. The Facility Administrator will monitor the Monthly Safety Checklist and fire extinguisher card to ensure completion each month.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2

Observations:
Name: FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER - Component: 10 - Tag: 0521

Based on document review and interview, it was determined the facility lacked documentation verifying the 1-year fire damper maintenance and exercise was performed, affecting the entire component.
Findings include:
1. Review of documentation on May 22, 2024, between 9:15 AM and 11:30 AM, revealed the facility failed to provide documentation of the 1-year fire damper exercise and maintenance, after installation. Installation was on 1/9/2023.
Interview with the Administrator and Clinical Director on May 22, 2024, at 1:30 PM, confirmed the facility could not provide documentation of the 1-year maintenance/exercise was performed.

Plan of Correction - To be completed: 06/30/2024

1. The Facility Administrator has contracted with a company who specializes in fire damper inspection. The Company will complete the 1-year fire damper exercise and maintenance, which was required after the initial installation. The Facility Administrator is working with the Company to secure a date for the 1-year inspection. The inspection is to be completed by June 30, 2024.

To ensure that the 1-year fire damper inspection is completed and documented, the Facility Administrator will maintain a checklist, which will also include subsequent inspections. The checklist will be reviewed upon completion of the 1-year and subsequent inspections to ensure completion and documentation. The checklist, which also contains inspection records for other elements of the building safety requirements, will be reviewed monthly by the Facility Administrator to ensure compliance.

NFPA 101 STANDARD Electrical Systems - Maintenance and Testing:

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Observations:
Name: FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER - Component: 10 - Tag: 0914

Based on document review and interview, it was determined the facility failed to provide verification of annual inspections of electrical receptacles in resident care areas, affecting the entire component.

Findings include:

1. Review of documentation on May 22, 2024, between 9:15 AM and 11:30 AM, revealed the facility lacked documentation verifying electrical receptacles were tested in the last 12 months.

Interview with the Administrator and Clinical Director on May 22, 2024, at 1:30 PM, confirmed the facility could not provide the annual electrical inspection documentation.

Plan of Correction - To be completed: 06/15/2024

1. The Property Management Building Engineer has been secured to complete the annual electrical receptacle testing. Once the annual testing is completed, the Building Engineer will provide documentation of completion to the Facility Administrator. The completion documentation will be kept on file in the Facility Building Safety binder. The Building Engineer has been scheduled to complete the electrical receptacle testing the week of June 8, 2024. The testing will be completed no later than Jun 15, 2024.
To ensure that the annual electrical receptacle testing is completed and documented, the Facility Administrator will maintain an annual checklist. The checklist will be reviewed upon completion of the annual testing to ensure timely completion and documentation. The checklist, which also contains inspection records for other elements of the building safety requirements, will be reviewed monthly by the Facility Administrator to ensure compliance.

NFPA 101 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: FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER - Component: 10 - Tag: 0918

Based on document review and interview, it was determined the facility failed to have the annual fuel quality sample performed for the emergency generator, which serves the entire component.

Findings include:

1. Review of documentation on May 22, 2024, between 9:15 AM and 11:30 AM, revealed the facility failed to verify the quality of the emergency fuel reserve for the emergency generator, within the previous twelve months.

Interview with the Administrator and Clinical Director on May 22, 2024, at 1:30 PM, confirmed the fuel sample test was not performed.

Plan of Correction - To be completed: 06/30/2024

Upon a review of the Service Agreement with Premium Power and FPPSC, it was identified that the Annual Fuel Quality Testing was not included in the agreement. The Facility Administrator has reached out to the Company to add the Annual Fuel Quality Testing to the agreement and complete the testing. Once the agreement is executed the testing will be scheduled and completed. The testing will be completed no later than June 30, 2024.

To ensure that the Annual Fuel Quality Testing is completed and documented, the Facility Administrator will maintain an annual Building Safety Checklist. All testing and inspection activity will be recorded on the Building Safety Checklist upon completion and documentation of the testing and inspection will be kept in the Facility Building Safety binder.

The Facility Building Safety Checklist and Binder which also contains inspection records for other elements of the building safety requirements, will be audited monthly by the Facility Administrator to ensure compliance. The audit will be conducted for a period of no less than 12 months. The audit will continue annually to ensure 100% compliance. Data will be reported to the Safety Committee on a quarterly basis.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement