QA Investigation Results

Pennsylvania Department of Health
BRANDYWINE VALLEY ENDOSCOPY CENTER
Building Inspection Results

BRANDYWINE VALLEY ENDOSCOPY CENTER
Building Inspection Results For:


There are  19 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 - Component - --

Based on an Emergency Preparedness Survey completed on December 22, 2020, it was determined that Brandywine Valley Endoscopy Center was not in compliance with the requirements of 42 CFR 416.54.



Plan of Correction:




416.54(b) STANDARD
Development of EP Policies and Procedures

Name - Component - --
403.748(b), 416.54(b), 418.113(b), 441.184(b), 460.84(b), 482.15(b), 483.73(b), 483.475(b), 484.102(b), 485.68(b), 485.625(b), 485.727(b), 485.920(b), 486.360(b), 491.12(b), 494.62(b).

(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.

*[For LTC facilities at 483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at 460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.

*[For ESRD Facilities at 494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Observations:

Based on document review and interview, it was determined the facility did not have a fire watch policy in the Emergency Preparedness Plan, which serves the entire component.

Findings include:

1. Review of documentation on December 22, 2020, at 11:15 AM revealed the Emergency Preparedness Plan lacked a Fire Watch Policy.

Interview at the time of the exit conference with the Administrator on December 22, 2020, at 11:50 AM confirmed the Emergency Preparedness Plan lacked a Fire Watch Policy.




Plan of Correction:

A policy has been written and approved by the Governing Body.
Policy states that in the event of a fire alarm system failure, a Fire Watch will be activated. The property manager will notify us if there is a fire system failure. The Administrator or designee will be responsible will initiate a Fire Watch. One individual will be assigned to the Fire Watch, and will have no other duties. That individual will check every room every 30 minutes. When checking the rooms, if the doors are closed, they will feel the door for heat, and observe for smoke or other indications that a fire may exist prior to opening the door. They will open the door slowly and make a visual/sensory inspection of the room. The Fire Watch is in effect until the alarm system is repaired, the building is evacuated, or at the end of the business day. A log will be maintained identifying who conducted the Fire Watch, date, time and any situations encountered. The person performing the Fire Watch will have control of communications and will sound a Code Red in the event of a fire and will call 911.
The Property manager will notify the Center when the fire alarm system has been repaired and all personnel will be notified.
All staff will be in-serviced on the Fire Watch Policy. A sign in sheet will be provided for training.


Initial Comments:
Name - MAIN BUILDING Component - 01

Facility ID #20501501
Component 01
Suite 320

Based on a Recertification/Relicensure Survey completed on December 22, 2020, at Brandywine Valley Endoscopy Center, it was determined there were no deficiencies identified under the 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 42 CFR 416.44(b).

This is a one-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.



Plan of Correction: