QA Investigation Results

Pennsylvania Department of Health
Building Inspection Results

Building Inspection Results For:

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Initial Comments:
Name - AREA D Component - 01
Facility ID# 17691501
Component 01
Main Building

Based on a Relicensure Survey completed on November 25, 2020, it was determined that Allegheny Surgery Center, LLC was not in compliance with the following requirements of the Life Safety Code for a existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).

This is a one-story, Type II (000), unprotected non-combustible building, without basement, that is fully sprinklered.

Plan of Correction:

28 Pa. Code 569.2 STANDARD
General Requirements - Other

Name - AREA D 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.

28 Pa. Code 51.3 Notification
(e) If a health care facility is aware of information which shows that the facility is not in compliance with any of the Department's regulations which are applicable to that health care facility, and that the noncompliance seriously compromises quality assurance or patient safety, it shall immediately notify the Department in writing of its noncompliance. The notification shall include sufficient detail and information to alert the Department as to the reason for the failure to comply and the steps which the health care facility shall take to bring it into compliance with the regulation.
(Editor ' s Note: Under section 314 of the act of March 20, 2002 (P. L. 154, No. 13) (act), subsections (f) and (g) are abrogated with respect to a medical facility upon the reporting of a serious event, incident or infrastructure failure pursuant to section 313 of the act.)
(11) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(12) Notification of termination of any services vital to the continued safe operation of the facility or the health and safety of its patients and personnel, including, but not limited to, the anticipated or actual termination of electric, gas, steam heat, water, sewer and local exchange telephone service.

Based on observation and interview, it was determined the facility failed to notify the Division of Safety Inspection that it replaced/upgraded the HVAC system, affecting the entire facility.

Findings include:

1. Based on observation and interview on November 25, 2020, at 10:00 a.m., it was determined the facility replaced/updated the HVAC system and did not contact the Division of Safety Inspection.

Interview with the Facility Director on November 25, 2020, at 10:00 a.m., confirmed that the Division of Safety Inspection had not been contacted in regards to the HVAC system replacement.

Plan of Correction:

1. How the facility will correct the deficiency: The facility upgraded the HVAC unit without prior notification to the Division of Safety Inspection prior to project implementation. The facility fully recognizes the omission of notification and for all future planned projects, upgrades, renovations will notify the Department of Life Safety prior to any changes. The facility is working with the building owner to acquire project plans to submit to the department for review on the HVAC unit that was installed
2. How the facility will protect patients in similar situations: The facility will proactively monitor all planned activity and upgrades that may affect patient care. Changes will be addressed by the facility's Quality Improvement Committee for action and planning. If projects may impact patient care, the QI committee will devise a plan to minimize or omit risk to patient care.
3. Measures the facility will take or systems it will alter to ensure so that the problem does not re-occur. The facility will review each quarter any planned projects or changes that may require notification to the Division of Life Safety. Record keeping will be a part of the quarterly QI responsibility and discussed at the quarterly meeting. Any issue or project requiring further action or notification to the Division of Life Safety will be addressed at that time.
4. How the facility plans to monitor its performance to make sure that the solutions are sustained: The facility will keep a monthly ledger; the "Maintenance Log" and note any changes or planned projects and document the same in the log. The log is reviewed quarterly and reviewed at the QI Meeting. Entries will be reviewed to assure that there were no issues that were were not "unreported" thus preventing a re-occurrence.
5. Date the facility will implement the corrective actions: the facility will implement the new tracking measures immediately and the monthly monitoring will be in place by the end of the current month 12-31-2020. Regarding reports of the current system that was installed without prior notification, the facility is working with the building owners to secure project plans for the installation of the HVAC unit and will submit them upon receipt.