QA Investigation Results

Pennsylvania Department of Health
BERKSHIRE EYE SURGERY CENTER
Building Inspection Results

BERKSHIRE EYE SURGERY CENTER
Building Inspection Results For:


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Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID #15291501
Component 01
Main Building

Based on a Relicensure Survey completed on March 9, 2021, it was determined that Berkshire Eye 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 one-story, Type V (000), unprotected wood frame structure, with a partial basement, which is fully sprinklered.


Plan of Correction:




28 Pa. Code 569.2 STANDARD
Gas Equipment - Precautions for Handling

Name - MAIN BUILDING 01 Component - 01
Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99).
11.6.2 (NFPA 99)

Observations:
Based on observation and interview, it was determined the facility failed to secure oxygen cylinders, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on March 9, 2021, at 10:02 AM revealed eight oxygen "E" cylinders laying unsecured on the floor of the Oxygen Storage Room.

Interview with the Administrator on March 9, 2021, at 10:02 AM confirmed the oxygen cylinders were not secured.



Plan of Correction:

An Oxygen E Tank holding rack has been ordered. This rack should arrive by 3/22/2021 and the oxygen tanks will be secured.

To keep the tanks secured until the rack arrives a large weighted block is being used to hold the tanks against the wall. It is like a weighted book end. The Clinical Director checks the Oxygen room daily to be sure the tanks have not moved. The Clinical Director will report the status of the oxygen tanks at the Governing Board Meeting.