Pennsylvania Department of Health
SAINT VINCENT SURGERY CENTER OF ERIE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SAINT VINCENT SURGERY CENTER OF ERIE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID # 45631500
Component 01
Main Building

Based on a Relicensure Survey completed on April 25, 2024, it was determined that Saint Vincent Surgery Center was not in compliance with the requirements of the Life Safety Code for an existing ambulatory health care occupancy.

This is a four-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

Based on observation and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting three of four floor levels.

Findings include:

Document review on April 25, 2024, at 10:24 a.m., revealed the facility failed to provide a set of accurate, portable floor plans for all floor levels. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:
a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

Interview at the exit conference with the medical director and maintenance supervisor on April 25, 2024, at 10:24 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable for all floor levels at the time of the survey.

Plan of Correction - To be completed: 07/31/2024

The Saint Vincent Surgery Center Manager of Facilities will be responsible to assure the following actions take place:
1. Complete and accurate floor plans will be developed by the AHN Manager of Facility Information Management.
2. These floor plans will contain all required information including smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls.
3.This work will be completed by July 31st
4. After the completion of these floor plans, copies will be held on the Share Point Site as well as paper copies in the Facility Manager's office.
5. A review for accuracy will be conducted Quarterly and after any completed construction or building modifications.
6. Deficiencies found and appropriate follow up will be reviewed at the monthly safety meeting.

28 Pa. Code § 569.2 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: MAIN BUILDING - Component: 01 - Tag: 0131

Based on observation and interview, the facility failed to meet multiple occupancy requirements on one of four building levels.

Findings include:

Observation on April 25, 2024, between 10:45 a.m. and 10:47 a.m., revealed the following code deficiencies for the basement's two-hour separation from healthy foods:
A. (10:45 a.m.) The two-hour door failed to positively latch in the frame;
B. (10:45 a.m.) The fire door lacked evidence of fire exit hardware;
C. (10:47 a.m.) The two-hour wall separation did not continue to the decking above.

Interview with the maintenance supervisor and medical director on April 25, 2024, at 10:47 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable at the time of the survey for the basement floor and confirmed deficiencies existed.

Plan of Correction - To be completed: 07/31/2024

The Saint Vincent Surgery Center Manager of Facilities will be responsible to assure the following actions take place:
1.A plan review Narrative will be written and submitted for the installation of a new set of 1-hour doors.
2.This addition will complete the separation of the Surgery Center from the non-Surgery Center Based Tenants.
3.This set of doors will show a solid barrier from the ambulatory health care occupancy from the other tenants and their occupancy.
4.Floor plans will be updated to show this new set of doors and the complete Department of Health Occupancy approval will be followed.
5.This new set of two-hour doors will have positive latching hardware. Any penetrations in the existing 1-hour wall separation to the deck will be filled and/or corrected.
6.This process will be completed by the Manager of Facilities.
7.The floor plans will be updated after the complete occupancy process to reflect this separation.
8. Door latching, penetration, and two-hour wall separations will be checked Quarterly by the Manager of Facilities
9.Deficiencies found and appropriate follow up will be reviewed at the monthly safety meeting.

28 Pa. Code § 569.2 STANDARD Electrical Systems - Receptacles:

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: MAIN BUILDING - Component: 01 - Tag: 0912

Based on observation and interview, the facility failed to meet receptacle requirements for one of one facility.

Findings include:

Document review on April 25, 2024, at 8:33 a.m., revealed the facility failed to provide documentation for the annual receptacle testing of non-hospital grade receptacles.

Interview with the maintenance supervisor and medical director on April 25, 2024, at 8:33 a.m., confirmed the documentation was unavailable at the time of the survey.

Plan of Correction - To be completed: 07/31/2024

The Saint Vincent Surgery Center Manager of Facilities will be responsible to assure the following actions take place:
1. All Non-Hospital Grade electrical outlets will be checked using the Receptacle Tension tester to ensure all non-hospital grade outlets are meeting the requirements.
2. A complete listing of all Non-Hospital Grade Receptacles will be added to a yearly Preventive Maintenace Program.
3. Quarterly reviews will be completed until all receptacle outlets are checked 1 x a year.
4. Deficiencies found and appropriate follow up will be reviewed at the monthly safety meeting.

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