Nursing Investigation Results -

Pennsylvania Department of Health
GRAND VIEW SURGERY CENTER AT HARLEYSVILLE, LLC
Building Inspection Results

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GRAND VIEW SURGERY CENTER AT HARLEYSVILLE, LLC
Inspection Results For:

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.
GRAND VIEW SURGERY CENTER AT HARLEYSVILLE, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0000


Facility ID# 24661501
Component 01
Harleysville Outpatient Center

Based on a Relicensure Survey completed on January 16, 2020, it was determined that Grandview Surgery Center at Harleysville 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 V (000), unprotected wood frame structure, which is fully sprinklered.




 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies:State only Deficiency.
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: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the one-hour fire resistance rating of tenant separation walls, affecting the entire facility.

Findings include:

1. Observation on January 16, 2020, between 10:15 am and 10:30 am, revealed unsealed penetrations of the tenant separation wall in the following locations:

a. 10:15 am, in the corridor above staff entrance doors, around MC cables;
b. 10:30 am, in the corridor across from mechanical room, open hole.

Interview at the exit conference with the Administrator and Director of Nursing on January 16, 2020, at 11:35 am, confirmed the unsealed penetrations.





 Plan of Correction - To be completed: 01/27/2020

Penetrations will be sealed by Feb.7, 2020 with an approved through penetration fire stop system. around all MC cables and wires. This will restore the integrity of the UL CEG-8-11-83 rating of the 1 hour fire wall. The facility will maintain the tenant separation.

The Exec. Director will randomly inspect all fire walls on a quarterly basis and as needed when any work is completed to ensure all penetrations are sealed properly.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:State only Deficiency.
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: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to ensure that automatic sprinkler systems were maintained free of external loads, affecting one of three floors.

Findings include:

1. Observation on January 16, 2020, at 10:40 pm, revealed, in the Electrical Room, 2 bundles of data wires were tied to the sprinkler piping.

Interview at the exit conference with the Administrator and Director of Nursing on January 16, 2020, at 11:35 am, confirmed the external loads on the sprinkler pipe.





 Plan of Correction - To be completed: 01/27/2020

By Jan 31, 2020, cables suspended by sprinkler piping shall be removed and secured to the wall.

Executive Director or appointed personnel shall audit the sprinkler pipes after work above the ceiling is performed by vendors.
NFPA 101 STANDARD HVAC:State only Deficiency.
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: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting the entire facility.

Findings include:

1. Document review on January 16, 2020, at 9:20 am, revealed the facility lacked documentation showing that required testing/inspection of the fire/smoke dampers was performed 1-year after installation.

Interview at the exit conference with the Administrator and Director of Nursing on January 16, 2020, at 11:35 am, confirmed fire/smoke damper inspection documentation was not on-site during the time of the survey.




 Plan of Correction - To be completed: 01/27/2020

Fire damper testing shall be completed by Feb. 28, 2020.

Executive director will review required testing needs on an annual basis to ensure future testing is completed when necessary.
NFPA 101 STANDARD Gas and Vacuum Piped Systems - Maintenance:State only Deficiency.
Gas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
Observations:
Name: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0907

Based on document review and interview, it was determined the facility failed to maintain the medical gas system, affecting four of four procedure rooms within the facility.

Findings include:

1. Document review on January 16, 2020, at 9:50 am, revealed the facility failed to conduct the required annual inspection of their med gas system.

Interview at the exit conference with the Administrator and Director of Nursing on January 16, 2020, at 11:35 am, confirmed the missing inspection.





 Plan of Correction - To be completed: 01/27/2020

Med gas system will be tested on Feb. 5, 2020. Executive Director will monitor required testing needs on an annual basis to ensure proper testing is completed on time.
NFPA 101 STANDARD Electrical Systems - Receptacles:State only Deficiency.
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.4.2 (NFPA 99)
Observations:
Name: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0912

Based on document review and interview, it was determined the facility failed to ensure that electrical receptacles were tested at patient bed locations within the facility.

Findings include:

1. Document review on January 16, 2020, at 9:00 am, revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:

a. visual inspection of physical integrity;
b. correct polarity of the hot and neutral connections;
c. retention force of the grounding blade (except locking-type receptacles) shall not be less than 4 oz.

The facility failed to conduct the retention test.

Interview at the exit conference with the Administrator and Director of Nursing on January 16, 2020, at 11:35 am, confirmed testing of electrical receptacles was not completed as required.




 Plan of Correction - To be completed: 01/27/2020

Retention testing of all required outlets will be completed by 2/3/2020.

Executive director will monitor required testing on an annual basis to ensure required testing is completed as necessary.

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