QA Investigation Results

Pennsylvania Department of Health
DELAWARE VALLEY LASER SURGERY INSTITUTE
Building Inspection Results

DELAWARE VALLEY LASER SURGERY INSTITUTE
Building Inspection Results For:


There are  23 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 B ASF Component - 01

Facility ID# 14271500
Component 01

Based on a Relicensure Survey completed on January 19, 2021, it was determined Delaware Valley Laser Surgery Institute was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Health Care Occupancy.

This is a nine-story, Type II (222), fire resistive construction, with a basement and lower level, which is fully sprinklered.

Approved as a Class B Ambulatory Surgical Facility.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Multiple Occupancies

Name - CLASS B ASF 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, interview and document review, it was determined the facility failed to maintain the fire resistance rating of tenant separation walls, affecting one of nine levels within this facility.

Findings include:

1. Observation on January 19, 2021, at 11:20 a.m., revealed, above the suspended ceiling, in Room C, unsealed penetrations of the tenant separation wall by two copper pipes.

Exit Interview with the Director of Nursing on January 19, 2021, at 12:30 p.m., confirmed the unsealed penetrations.





Plan of Correction:

1/20/2021 the cited unsealed penetrations of the tenant separation wall by two copper pipes in Room C was sealed utilizing Fire grade caulk by the buildings maintenance department.

Center closed it's doors for good as of 02/26/2021


28 Pa. Code 569.2 STANDARD
Means of Egress - General

Name - CLASS B 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 observation, document review and interview, it was determined the facility failed to maintain required inspections of fire rated door openings, free of obstructions, affecting the entire facility.

Findings include:

1. Document review on January 19, 2021, at 9:00 a.m., revealed the 2020 Annual Fire Door Inspection report listed 11 rated doors as deficient. The repairs remained uncorrected at time of survey.

Exit Interview with the Director of Nursing on January 19, 2021, at 12:30 pm, confirmed the incomplete repairs to the rated door assemblies.

2. Observation on January 19, 2021, at 10:00 a.m., revealed Pre-PACU exit discharge door was sticking to the frame and difficult to open.

Exit Interview with the Director of Nursing on January 19, 2021, at 12:30 p.m., confirmed the exit door impediment.





Plan of Correction:

The parts and Fire doors for the 11 noted Fire doors of the 2020 Annual Fire Door Inspection report were placed on order with Johnson Control Inc. The parts and doors ordered 1/19/2020 will take 8-12 weeks to be delivered to the company, at which time the deficient doors will be replaced


28 Pa. Code 569.2 STANDARD
Emergency Lighting

Name - CLASS B ASF Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9

Observations:

Based on observation and interview, it was determined the facility failed to ensure battery back-up lighting was maintained in operable condition, affecting one of four floors.

Findings include:

1. Observation on January 19, 2021, at 9:15 a.m., revealed, by Pre-PACU emergency exit door, the exterior battery back-up remote head failed to illuminate when tested.

Exit Interview with the Director of Nursing on January 19, 2021, at 12:30 p.m., confirmed the battery back-up light failed to illuminate when tested.





Plan of Correction:

The battery back-up lighting remote head was replaced on 01/20/2021, and tested. It did illuminate when tested.

center closed for good 2/26/21


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 in operable condition, affecting the entire facility.

Findings include:

1. Document review on January 19, 2021, at 8:45 a.m., revealed the September 29, 2020 Fire Alarm Inspection Report indicated the following devices failed when tested:

a. 1- manual pull;
b. 1- duct detector;
c. 1- magnetic door lock release device;
d. 4- strobes;
e. 23- speaker strobes.

These conditions remained uncorrected at time of survey.

Exit Interview with the Director of Nursing on January 19, 2021, at 12:30 p.m., confirmed the deficiencies remained uncorrected at time of survey.





Plan of Correction:

The fire alarm system inspection report indicated 5 devices which failed when tested
a. 1 - manual pull;
b. 1 duct detector;
c. 1 - magnetic door lock release device
d. 4 strobes;
e. 23 speaker strobes.

none were located in the facility but within the 2 bala plaza building in other offices and hallways. A these conditions were corrected 01/25/2021 when the contracted company returned with the ordered parts for the repair. All devices were retested and passed.

center closed 2/26/21


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

Name - CLASS B 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 ensure automatic sprinkler system components were maintained free of debris, affecting one of two smoke compartments.

Findings include:

1. Observation on January 19, 2021, at 10:15 a.m., revealed a sprinkler, with a buildup of corrosion, in PACU Bay 1.

Exit Interview with the Director of Nursing on January 19, 2021, at 12:30 p.m., confirmed the corroded sprinkler.





Plan of Correction:

A&S sprinkler company was notified the sprinkler head in bay 1 of the Pre/PACU area needed replacement due to corrosion on the head. The parts were ordered and repair slated for 3/10/2021

center closed 2/26/2021


28 Pa. Code 569.2 STANDARD
HVAC

Name - CLASS B ASF Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2

Observations:

Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting the entire facility.

Findings include:

1. Document review on January 19, 2021, at 9:30 a.m., revealed the facility lacked documentation a four-year inspection/exercise of the fire/smoke fire dampers was performed.

Exit Interview with the Director of Nursing on January 19, 2021, at 12:30 p.m., confirmed damper inspection documentation was not available.





Plan of Correction:

The 4 year inspection/exercise of the fire/smoke fire dampers was scheduled for the last week of March 2021. The facility has since been closed due to financial decisions related to the pandemic.


28 Pa. Code 569.2 STANDARD
Electrical Systems - Maintenance and Testing

Name - CLASS B ASF 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 maintain inspection of electrical wiring and receptacle systems, affecting the entire facility.
Findings include:
1. Document review on January 19, 2021, at 9:45 a.m., revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested at intervals not exceeding 12 months for non-hospital grade receptacles, or based on documented performance data not exceeding 12 months for hospital grade receptacles. Receptacle testing should include the following:

a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).

Exit Interview with the Director of Nursing on January 19, 2021, at 12:30 p.m., confirmed the test was not performed within the prior 12 months.





Plan of Correction:

the annual inspection of the electrical receptacles at patient bed locations, and in locations where Monitored anesthesia care, as no deep sedation nor general anesthesia is performed at this facility, was scheduled to occur March 16,2021. The facility closed as of 02/27/2021 for business.