QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - MAIN BUILDING Component - 02

Facility ID# 17171501
Component 02
Main Building

Based on a Relicensure Survey completed on June 8, 2022, it was determined that Berks Ambulatory Surgery Center, Llc 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 28 Pa Code 569.2.

This is a one-story, Type V (000), unprotected wood frame structure, without a basement, which is not sprinklered.

Plan of Correction:

28 Pa. Code 569.2 STANDARD
Emergency Lighting

Name - MAIN BUILDING Component - 02
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.,, 7.9


Based on observation and interview, it was determined the facility failed to maintain battery-powered emergency lighting sources, affecting the entire component.

Findings include:

1. Observation on June 8, 2022, at 10:50 AM, revealed battery-powered emergency lights, in the back hall, outside the Staff Lounge, are inoperable.

Interview at the time of the exit conference with the Administrator and OR Supervisor on June 8, 2022, at 11:45 AM, confirmed the battery-powered emergency lights did not work.

Plan of Correction:

In order to maintain emergency lighting of at least 1-1/2 hour duration throughout the Center, a new battery-powered emergency lighting unit was ordered on June 17, 2022, by the Center's contractor, to replace the inoperable unit the back hallway. An installation date of July 1, 2022, has been scheduled, pending delivery of the unit.

The Administrator will be responsible for verifying that the new emergency light has been installed. The DON is responsible for the monthly checks and annual 90 minute test on all emergency battery-powered lights in the Center and will maintain documentation in the Center's Maintenance Log Book and the Surgilog online.