Pennsylvania Department of Health
JEFFERSON SURGICAL CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 9 surveys for this facility. Please select a date to view the survey results.

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JEFFERSON SURGICAL CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: JEFFERESON SURGICAL CENTER - Component: 01 - Tag: 0000

Facility ID# 24681501
Component 01

Based on a Relicensure Survey completed on June 5, 2023, it was determined that Jefferson Surgical Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is an eight story, Type II (222) fire resistive construction, with a basement and mechanical penthouse, which is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Subdivision of Building - Smoke Barrier:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5

Observations:
Name: JEFFERESON SURGICAL CENTER - Component: 01 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls, affecting the entire component.

Findings include:

1. Observations on June 5, 2023, between 10:03 am and 10:09 am, revealed open penetrations and openings in the smoke barrier wall in the following locations:

a. 10:03 am, above the smoke barrier door by the Nurse Manager's Office, an open penetration by data wires;
b. 10:09 am, above the ceiling in PACU Bay A and Bay B, several openings.

Exit interview with the Director of Maintenance on June 5, 2023, at 10:45 am, confirmed the openings/penetrations in the smoke barrier wall.

Plan of Correction - To be completed: 06/10/2023

Facilities repaired the penetrations in the rated smoke barrier with UL listed through-penetration firestop systems, WL 3071 and WL 5223. Work was finished on 6/10/23. Facilities conducted a survey of the entire smoke barrier on both sides and will include future above-ceiling smoke barrier inspections during semi-annual rounding. Compliance with these inspections will be reported at the Environment of Care Committee Meeting.

28 Pa. Code § 569.2 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: JEFFERESON SURGICAL CENTER - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire component.

Findings include:

1. Document review on June 5, 2023, at 8:30 am, revealed the facility could not produce documentation of the following tests and inspections:

a. Monthly testing of battery electrolyte specific gravuity or conductance;
b. Preventative maintenance indicating no evidence of wet-stacking;
c. Annual fuel quality test.

Exit interview with the Director of Maintenance on June 5, 2023, at 10:45 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 06/30/2023

Facilities has reviewed and corrected the PM schedule for the emergency generator. Weekly inspections will include voltage testing of sealed batteries and monthly will include conductivity testing of sealed batteries. Compliance manager will collect these reports by the 1st week of each month.

Facilities has completed a generator PM conducted by Foley CAT on 3/22/23. This included investigation showing no evidence of wet stacking. This PM will be conducted annually in the first quarter of the calendar year.

Center Point Tank Services conducted fuel quality testing on 6/15/22. Documentation of this was located and filed correctly. Same vendor is conducting the 2023 testing, and documentation will be available no later than the end of June.

The Assistant Director of Facilities Compliance will review documentation quarterly to ensure that all fuel and generator testing documents are readily available going forward.

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