Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on June 11, 2026, at Wellspan Endoscopy Center in Lewisburg, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 20561501
Component 01
Building 01
Based on a Recertification Survey completed on June 11, 2026, it was determined that Wellspan Endoscopy Center in Lewisburg 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, wood frame building, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Multiple Occupancies
Name - MAIN BUILDING Component - 01
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:
Based on observation and interview, it was determined the facility failed to maintain one tenant separation wall, affecting one of two floors.
Findings include:
1. Observation on June 11, 2026, at 9:53 am, revealed two unsealed penetrations of the tenant separation wall, located above the separation door near the women's locker room.
Exit interview with Facility Representative One and Facility Representative Two on June 11, 2026, at 10:30 am, confirmed the tenant separation wall penetrations.
Plan of Correction:Finding Observation:
Observation on June 11th, 2026 at 9:53 a.m. revealed two unsealed penetrations of the tenant separation wall, located above the separation door near the women's locker room at the WellSpan Endoscopy Center in Lewisburg.
Plan of Correction:
Work order #T0117000 was entered on June 12, 2026 and completed on June 12, 2026. The penetrations were properly sealed with the appropriate fire stop material per the appropriate UL system.
Systemic Changes Implemented to Prevent Recurrence of the Deficiencies:
Engineering will ensure the above ceiling access permit process is followed per WellSpan corporate MAP-1098 "Barrier Management Policy". Any vendor or WellSpan department doing work above the ceiling will have the planned above ceiling work reviewed and issued a permit. When the work is completed, Engineering will complete a visual inspection of the above ceiling work to ensure compliance. A monthly report of permit process will be sent to the supervisor of Accreditation and Licensure.
Person Responsible for Corrective Actions:
Manager of Engineering
Method for Monitoring:
Tasks as described above.
Frequency of Monitoring:
Monthly
Measure of Effectiveness:
100% of PM activities will demonstrate compliance with NFPA Standards.
Corrective actions will be determined effective after three consecutive months of 100% compliance. Monitoring results will be provided by the Manger of Engineering and reported at the quarterly endoscopy center's Quality Management Council (QMC) by the supervisor of Accreditation and Licensure. After sustained compliance is achieved, Engineering will continue to ensure all vendors complete the above ceiling permit and understand the permitting process for any work above the ceiling grid.
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