QA Investigation Results

Pennsylvania Department of Health
BUCKS COUNTY GI ENDOSCOPIC SURGICAL CENTER, LLC
Building Inspection Results

BUCKS COUNTY GI ENDOSCOPIC SURGICAL CENTER, LLC
Building Inspection Results For:


There are  21 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - CLASS B ASF Component - 01

Facility ID# 20471501
Component 01

Based on a Relicensure Survey completed on December 7, 2020, it was determined Bucks County Gi Endoscopic Surgical Center, Llc 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 construction, which is non-sprinklered.

Licensed as a Class B Ambulatory Surgical Facility.





Plan of Correction:




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 ensure fire/smoke dampers were exercised within the required time frame, affecting the entire facility.

Findings include:

1. Document review on December 7, 2020, at 8:30 a.m., revealed the facility could not provide documentation fire/smoke dampers had been exercised within the previous 48 months.

Interview at the exit conference with the Office Administrator and Director of Nursing, on December 7, 2020, at 11:20 a.m., confirmed the documentation was not available.






Plan of Correction:

Comprehensive Test and Balance,INC came out to the facility to visually inspect and exercise the dampers

Inspection was done on 12/11/2020

The Administrator will be responsible to make sure the dampers are inspected and exercised every 4 years.

The Dampers have been added to our Annual Audit List and will be reported to the Safety Committee Annually


28 Pa. Code 569.2 STANDARD
Electrical Systems -Essential Electric System

Name - CLASS B ASF Component - 01
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:

Based on document review and interview, it was determined the facility failed to maintain required inspections of emergency generator components, affecting the entire facility.

Findings include:

1. Document review on December 7, 2020, at 8:30 a.m., revealed the facility could not provide documentation monthly conductance testing was being performed on the emergency generator's maintenance free sealed battery.

Interview at the exit conference with the Office Administrator and Director of Nursing, on December 7, 2020 at 11:20 a.m., confirmed the documentation was not available.






Plan of Correction:

Conductance testing, has been added to our monthly schedule for our emergency generator maintenance free sealed battery.

We purchased a Foxwell BT-780 Battery Analyzer Auto Car Battery Tester Diagnostic Tool 12v/24v as recommended by our Generator Contractor.

The Administrator will be responsible to make sure this testing is done on a monthly basis.

The Center will perform a quarterly audit of the weekly visual inspection and will be reported to the safety committee quarterly