Pennsylvania Department of Health
SURGERY CENTER AT FORT WASHINGTON, THE
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SURGERY CENTER AT FORT WASHINGTON, THE - 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 June 6, 2024, at Surgery Center at Fort Washington, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.

Plan of Correction:

Initial comments:Name: FOUNDATION SURGERY AFFILIATES AT FORT WASHINGTON - Component: 02 - Tag: 0000

Facility ID # 55551500
Building 02

Based on a Recertification/Relicensure Survey completed on June 6, 2024, it was determined that Surgery Center at Fort Washington 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 two story, Type II (000), unprotected non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

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: FOUNDATION SURGERY AFFILIATES AT FORT WASHINGTON - Component: 02 - Tag: 0372

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of two levels.

Findings include:

Observation on June 6, 2024, at 9:50 a.m., revealed an unsealed open hole penetration above the suspended ceiling in Receiving 131.

Exit Interview with the Director of Nursing on June 6, 2024, at 10:30 a.m., confirmed the unsealed penetration.

Plan of Correction - To be completed: 06/19/2024

The Administrator requested the
presence of the Building Mechanical
Contractor to be on site immediately
following inspection. The facility
used an approved through
penetration fire stop system to seal
the penetrations through the rated
partition. The UL Design is on file
with the Life Safety Plan of
correction at the facility.
A semi annual above ceiling
compliance check will be performed
to ensure the Fire Stop system has
not been compromised and reported
to the patient safety committee.

NFPA 101 STANDARD Electrical Systems - Other:

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: FOUNDATION SURGERY AFFILIATES AT FORT WASHINGTON - Component: 02 - Tag: 0911

Based on observation and interview, it was determined the facility failed to protect electrical wiring, affecting one of two levels.

Findings Include:

Observation on June 6, 2024, at 10:00 a.m., revealed exposed wires at abandoned temporary lighting, sprinkler riser room on the first floor.

Exit Interview with the Director of Nursing on June 6, 2024, at 10:30 a.m., confirmed the exposed wires.

~Refer to the 2011 edition of NFPA 70, 314.28 (C)

Plan of Correction - To be completed: 06/19/2024

The facility Administrator has contacted the building owner/management company to remove the temporary lighting in the building's sprinkler/mechanical room. The facility was advised by the building management that the lighting has been removed and verified by facilities inspection. The facility will do a visual monthly verification check of the sprinkler/mechanical room to ensure compliance and report the results to the Patient Safety Committee. The facility will notify the building management if they are out of compliance. The facility will continue ongoing monthly visual verification moving forward.

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