Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 17401501
Component 01
Main Building
Based on a Relicensure Survey completed on January 22, 2026, it was determined that Liberty Eye Surgery Center, Llc 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 II (000), unprotected, non-combustible building, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING 01 Component - 01
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:
Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.
Findings include:
Document review on January 22, 2026, at 9:30 a.m., revealed the facility failed to provide documentation for the following sprinkler system inspections:
a. 3rd quarter sprinkler inspection.
b. 5-year internal pipe and valve inspection.
Exit interview with the Administrator on January 22, 2026, at 10:15 a.m., confirmed the missing documentation.
Plan of Correction:All 4 quarterly sprinkler inspections for 2026 have been scheduled. The quarterly inspections will occur Jan, April, July, and October (the first month of each quarter so that if there are call outs or cancelations there is time to reschedule). A Quote for the 5 year sprinkler inspection was signed and submitted to cintas on 2/5/26. 5 year Inspection scheduled for 2/27/26. Administrator responsible for scheduling quarterly and all other maintenance on sprinkler system.
28 Pa. Code § 569.2 STANDARD
Electrical Systems - Maintenance and Testing
Name - MAIN BUILDING 01 Component - 01
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles at patient bed locations were tested as required, affecting one of three test parameters.
Findings include:
Document review on January 22, 2026, at 9:00 a.m., revealed electrical receptacles at patient bed locations, were not tested as required for non-hospital grade receptacles at intervals 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 did not include b.) correct polarity of the hot and neutral connections.
Exit interview with the Administrator on January 22, 2026, at 10:15 a.m., confirmed incomplete testing of electrical receptacles.
Plan of Correction:Electrician scheduled to come out and complete inspection for grounding, polarity and tension on 2/20/2026. A New Receptacle Testing checklist documenting the inspection of all 3 requirements (grounding, polarity & tension) was created then approved by the governing board for use. Administrator will be responsible for scheduling yearly inspections and supplying electrician with required checklist.
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