QA Investigation Results

Pennsylvania Department of Health
DERMATOLOGIC SURGICENTER - PHILADELPHIA
Building Inspection Results

DERMATOLOGIC SURGICENTER - PHILADELPHIA
Building Inspection Results For:


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Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID #04841500
Component 01

Based on a Relicensure Survey completed on March 13, 2023, it was determined that Dermatologic Surgicenter - Philadelphia 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 four story, Type V (111), protected wood frame construction, with a basement, which is non-sprinklered.

Approved as a Class B Ambulatory Surgical Facility.



Plan of Correction:




28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Testing and Maintenance

Name - CLASS B ASF Component - 01
Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5

Observations:
Based on document review and interview, it was determined the facility failed to maintain Fire Alarm components, affecting the entire facility.

Findings include:

1. Document review on March 13, 2023, at 9:00 am, revealed the facility could not produce documentation that a semi-annual fire alarm inspection had been performed.

Exit Interview with the RN and the Histo-tech on March 13, 2023, at 10:20 am, confirmed the missing documentation.




Plan of Correction:

We will send a registered / certified receipt letter to the contracted company responsible for our semi-annual inspection explaining the mandatory necessity that they complete the inspection in the required time frame for the regulation of the PA Department of Health.

We will post a maintenance list for our administrative assistant and assign her the task of reminding the contracted company before the due date of the next inspection.

The administrative assistant, nurses, and medical director will be in-serviced on the necessity of proper surveillance to ensure compliance.

These actions will be reported to the Quality Assurance Risk Management Committee who will inform the Governing Body of the same.


28 Pa. Code § 569.2 STANDARD
Portable Fire Extinguishers

Name - CLASS B ASF Component - 01
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:
Based on document review and interview, it was determined the facility failed to ensure fire extinguishers were inspected by certified inspectors, for one of one inspection.

Findings Include:

1. Document review on March 13, 2023, at 9:10 am, revealed documentation was unavailable verifying personnel providing servicing and recharging of portable fire extinguishers were credentialed.

Exit Interview with the RN and the Histo-tech on March 13, 2023, at 10:20 am, confirmed the missing documentation.




Plan of Correction:

We will send a registered / certified return receipt letter to our contracted company who completes our annual fire extinguisher inspection.

We will notify them that we need a copy of the technician certification annually to keep on file at our facility. This will be kept in the Life Safety Binder.

The administrative assistant, nursing staff, and medial director will all be aware of this Life Safety requirement.

An in-service will be completed with involved staff regarding the requirement. This will be placed in the In-service Binder

These actions will be reported to the Quality Assurance Risk Management Committee who will inform the Governing Body of the same.


28 Pa. Code § 569.2 STANDARD
Electrical Systems - Other

Name - CLASS B ASF Component - 01
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.

Observations:

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of four floors.

Findings include:

1. Observation on March 13, 2023, at 9:45 am, revealed in the basement panel room, a duplex receptacle was missing its protective cover plate, exposing the inner wiring.

Exit Interview with the RN and the Histo-tech on March 13, 2023, at 10:20 am, confirmed the missing cover.

~Refer to 2011 edition of NFPA 70-314.28.





Plan of Correction:

The protective cover plate for the duplex receptacle will be installed as soon as possible.

We will start a check sheet monitoring that all receptacles have proper covers. We will check receptacles for all areas of the ASC monthly for 6 months. Our anticipated outcome is 100% compliance. The check sheet will be placed in the Life Safety Binder.

The histotech or nursing staff will be responsible for the documentation and surveillance of the receptacle protective cover plates.

An in-service will be done to include the safety check / monitoring at our facility.

These actions will be reported to the Quality Assurance Risk Management Committee who will inform the Governing Body of the same.