QA Investigation Results

Pennsylvania Department of Health
CENTER FOR SPECIALIZED SURGERY, L.P., THE
Building Inspection Results

CENTER FOR SPECIALIZED SURGERY, L.P., THE
Building Inspection Results For:


There are  18 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 - ASF Component - 01

Facility ID# 20721501
Component 01
Main Building

Based on a Relicensure Survey completed on April 27, 2021, it was determined that The Center for Specialized Surgery, L.P., was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a two story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.





Plan of Correction:




28 Pa. Code 569.2 STANDARD
Hazardous Areas - Enclosure

Name - ASF Component - 01
Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7

Observations:

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of two floors.

Findings include:

1. Observation on April 27, 2021, at 10:12 a.m., revealed several holes were located within the storage room door.

Exit interview with the Facility Administrator on April 27, 2021, between 11:10 a.m. and 11:15 a.m., confirmed the hazardous area enclosure deficiency.






Plan of Correction:

Hole in storage room door will be repaired with appropriate fire barrier/filler to meet NFPA standards.
Action will be completed by 5/28/2021.
A bi-annual fire/smoke door inspection will be done in place of current annual only inspection. This added inspection will be scheduled an performed by our biomed building technician. A log will be maintained documenting inspection was performed, if any repairs were needed or not and repairs were completed if necessary.


28 Pa. Code 569.2 STANDARD
Gas and Vacuum Piped Systems - Signs

Name - ASF Component - 01
Gas and Vacuum Piped Systems - Information and Warning Signs
Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency.
5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)

Observations:

Based on observation and interview, it was determined the facility failed to maintain the medical gas system in one location, affecting one of two floors.

Findings include:

1. Observation on April 27, 2021, at 10:22 a.m., revealed vacuum piping within Boiler Room lacked stenciling.

Exit interview with the Facility Administrator on April 27, 2021, between 11:10 a.m. and 11:15 a.m., confirmed the medical gas system deficiency.




Plan of Correction:

Lack of Label/stenciling of vacuum piping will be correctly labeled to meet life safety standards
Action will be completed by 5/28/2021.
An annual inspection will be scheduled and performed with our HVAC provider as part of the routine annual inspections. A log will be maintained documenting inspection was performed and completed and any discrepancies/deficiencies were appropriately taken care of.