QA Investigation Results

Pennsylvania Department of Health
CROZER-KEYSTONE SURGERY CENTER AT HAVERFORD (A DEPARTMENT OF
Building Inspection Results

CROZER-KEYSTONE SURGERY CENTER AT HAVERFORD (A DEPARTMENT OF
Building Inspection Results For:


There are  22 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - CLASS C ASF Component - 01

Facility ID# 10271500
Component 01
Main Building

Based on a Relicensure Survey completed on December 20, 2022, it was determined Crozer-Keystone Surgery Center At Haverford, was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a three-story, Type II (000), unprotected non-combustible construction, with a basement, which is fully sprinklered.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Means of Egress - General

Name - CLASS C ASF Component - 01
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1

Observations:

Based on document review and interview, it was determined the facility failed to maintain means of egress free of all obstructions, affecting the entire facility.

Findings include:

1. Document review on December 20, 2022, at 8:15 a.m., revealed the facility could not produce a snow removal policy.

Exit interview with the Director of Facilities on December 20, 2022, at 9:45 a.m., confirmed the lack of documentation.





Plan of Correction:

The Snow Removal Policy was located after the conclusion of the survey. This Snow Removal Policy will be reviewed and updated by the Director of Facilities and uploaded to the health system's policy software, PolicyTech, by 2/10/23.

This policy will be updated by the Director of Facilities or a designee annually or sooner when changes are needed. The policy has also been added to the Facilities Department inspection book.

The Director of Facilities is ultimately responsible for this plan of correction.


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

Name - CLASS C 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 and inspect the fire alarm system, affecting the entire facility.

Findings include:

1. Document review on December 20, 2022, at 8:15 a.m., revealed the facility did not conduct a semi-annual visual inspection of the fire alarm system within six months of June 4, 2022.

Exit interview with the Director of Facilities on December 20, 2022, at 9:45 a.m., confirmed the lack of semi-annual visual inspection.





Plan of Correction:

The Director of Facilities conducted a visual inspection of the fire alarm system on 12/23/22.

Subsequent semi-annual visual inspections of the fire alarm system will be scheduled accordingly. Future inspections have been entered into the system's work order program to ensure completion. These inspections will be conducted by the Director of Facilities or a designee.

The Director of Facilities is ultimately responsible for this plan of correction.


28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - CLASS C ASF 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 observation and interview, it was determined the facility failed to maintain the sprinkler system, affecting one of two smoke compartments.

Findings include:

1. Observation on December 20, 2022, at 9:15 a.m., revealed the Storage Room, by Advanced Recovery, missing ceiling tiles which could delay the activation of sprinklers.

Exit interview with the Director of Facilities on December 20, 2022, at 9:45 a.m., confirmed the missing ceiling tiles.


2. Observation on December 20, 2022, between 9:15 a.m. and 9:30 a.m., revealed storage within 18" of sprinklers, following locations:

a. 9:15 a.m., Storage Room, by Advanced Recovery;
b. 9:30 a.m., Bulk Storage.

Exit interview with the Director of Facilities on December 20, 2022, at 9:45 a.m., confirmed the storage within 18" of sprinklers.





Plan of Correction:

The Director of Facilities will replace missing ceiling tiles by 2/10/23. The Director of Facilities or a designee will monitor for this moving forward during semi-annual Environment of Care rounds.

The Clinical Director removed all storage that was identified to be within 18 inches of the ceiling. All staff will be educated on the requirement to keep storage at least 18 inches from sprinklers by 2/10/23. The Clinical Director or a designee will complete audits weekly to ensure nothing is stored within 18 inches of sprinklers. Any identified instance of non-compliance will be reported to the site Administrator and corrected immediately. Audits will continue until 100% compliance has been achieved for 2 consecutive months

The Administrator of Haverford Surgery Center is ultimately responsible for this plan of correction.