QA Investigation Results

Pennsylvania Department of Health
CROZER-KEYSTONE SURGERY CENTER AT BRINTON LAKE (A DEPARTMEN
Building Inspection Results

CROZER-KEYSTONE SURGERY CENTER AT BRINTON LAKE (A DEPARTMEN
Building Inspection Results For:


There are  21 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 C ASF Component - 01

Facility ID# 18841501
Component 01


Based on a Relicensure Survey completed on October 20, 2022, it was determined Crozer-Keystone Surgery Center at Brinton Lake 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 III(200), unprotected ordinary construction, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility (ASF).




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Illumination of Means of Egress

Name - CLASS C ASF Component - 01
Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention.
20.2.8, 21.2.8, 7.8


Observations:

Based on document review and interview, it was determined the facility failed to maintain emergency lighting, affecting the entire component.

Findings include:

1. Document review on October 20, 2022, at 8:15 a.m., revealed the facility could not provide documentation the emergency lights had been tested for 90-minutes in the past 12 months.

Exit interview with the Administrator and Maintenance Director on October 20, 2022, at 9:45 a.m., confirmed the lack of documentation.





Plan of Correction:

On 10/25/2022 the Administrative Director of the Surgery Center confirmed with Facilities Leadership that the 2022 Life Safety Checklist which included battery power lights being tested for 30 seconds each month and at least 90 minutes annually was completed. Moving forward the Director of Facilities will ensure that all required survey documentation is completed as required and is available at the time of survey. In addition, Facilities staff will provide completed monthly and annual testing documentation to the Director of Facilities and the Administrative Director of the Surgery Center for review. Any instances of noncompliance will be addressed with staff by the Director of Facilities.