Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 12871501
Component 01
Main Building
Based on a Relicensure Survey completed on May 27, 2025, it was determined that Einstein Surgery Center 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 noncombustible building, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
General Requirements - Other
Name - CLASS C ASF Component - 01
General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.
Observations:
28 Pa. Code 553.3(1) GOVERNING BODY RESPONSIBILITIES
Governing body responsibilities include:
(1) Conforming to applicable Federal, State and local law. This REGULATION has not been met.
35 P.S. 448.808. Issuance of license.
(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.
Based on observation, document review, and interview, it was determined the following items did not conform to applicable Federal, State and local laws and regulations:
Findings include:
Document review and observation on May 27, 2025, at 9:30 a.m. revealed the facility failed to secure plan approval by the Department of Health prior to installing new outlets, inlets, zone valves and area alarm panel for Procedure Room 119.
Exit Interview with the Facilities Manager and Property Manager on May 27, 2025, at 10:30 a.m., confirmed the DOH Approval for the medical gas system alterations was unavailable at time of survey.
28 Pa Code 51.3. Notification (d)
Plan of Correction:The Administrator is responsible for this plan of correction.
The new outlets, inlets, zone valves and area alarm panel for Procedure Room 119 will not be placed into service until approval is formally given from the Department of Health.
The facility property management company will work with Jefferson Planning, Design and Construction to assess and submit the plans for approval from the Department of Health.
The approved project will be reported to the next Einstein Surgery Center Patient Safety Committee meeting following completion.
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 smoke detectors within the facility.
Findings include:
Document review on May 27, 2025, at 9:00 a.m., revealed documentation of smoke detector sensitivity testing was unavailable at time of survey.
Exit Interview with the Facilities Manager and Property Manager on May 27, 2025, at 10:30 a.m., confirmed smoke detector sensitivity testing was not available at time of survey.
Plan of Correction:The Administrator is responsible for this plan of correction.
Sensitivity testing of the smoke detectors was conducted on Tuesday, 6/17/2025. The method for testing the sensitivity will be conducted at each individual smoke detector. This methodology provides a more accurate assessment of the smoke detectors.
The results of this testing will be reviewed by Facilities Regulatory Compliance and all necessary work orders and corrections will be addressed by the property management company under the supervision of Facilities Regulatory Compliance.
All future fire alarm inspections will be audited by Facilities Regulatory Compliance upon completion of the inspection.
This plan of correction will be reported to the Einstein Surgery Center Patient Safety Committee meeting following completion.
28 Pa. Code § 569.2 STANDARD
Subdivision of Building - Smoke Barrier
Name - CLASS C ASF Component - 01
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:
Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting one of three levels.
Findings include:
Observation on May 27, 2025, at 9:40 a.m., revealed an unsealed penetration around MC wire, the scope room on the first floor.
Exit Interview with the Facilities Manager and Property Manager on May 27, 2025, at 10:30 a.m., confirmed the penetration.
Plan of Correction:The Administrator is responsible for this plan of correction.
The identified penetration was corrected the day of the survey using approved fire stop system # W-L-3195, per the manufacturer, 3M.
The property management company will conduct monthly barrier assessments until 3 months of 100% compliant assessments have occurred. Documentation of the assessments will be provided to the Administrator. Upon the completion of the 3 months of 100% compliance, the property management company will perform the assessment annually. All barrier assessments will be validated and reviewed by Facilities Regulatory Compliance. Any repairs to the barrier will use only approved through-penetration fire stop systems.
This plan of correction will be reported to the Einstein Surgery Center Patient Safety Committee meeting following completion.
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