QA Investigation Results

Pennsylvania Department of Health
CORNERSTONE AMBULATORY SURGERY CENTER LLC
Building Inspection Results

CORNERSTONE AMBULATORY SURGERY CENTER LLC
Building Inspection Results For:


There are  23 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 August 2, 2023, at Cornerstone Ambulatory Surgery Center Llc, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.




Plan of Correction:




Initial Comments:
Name - (CLOSED) CLASS C ASF Component - 01

Facility ID# 21331501
Component 01
Main Building

Based on a Recertification/Relicensure Survey completed on August 2, 2023, it was determined that Cornerstone Ambulatory Surgery Center Llc, was not in compliance with the following 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 V (000), unprotected wood frame construction, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.




Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - (CLOSED) CLASS C ASF Component - 01
Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:

Based on document review and interview, it was determined the facility failed to maintain fire alarm system components, affecting the entire facility.

Findings include:

1. Document review on August 2, 2023, at 11:20 am, revealed documentation of smoke detector sensitivity testing was not available at time of survey.

Exit interview with the Administrator on August 2, 2023, at 1:15 pm, confirmed smoke detector sensitivity testing was not available at time of survey.





Plan of Correction:

Observations #: 0345
Fidelity Alarm Company performed the inspection of smoke detector sensitivity testing on August 9,2023. The smoke detector sensitivity test was performed to find no deficiencies on August 9,2023.
In accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72. The CASC will add smoke detector sensitivity testing to their annual inspection by Fidelity Alarm Company.
The DON will be responsible for monitoring ongoing compliance. This will be discussed at our next staff meeting and will continue to be checked on our preventative Maintenance Checklist and Life Safety checklist.



NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste

Name - (CLOSED) CLASS C 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 documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

1. Document review on August 2, 2023, at 11:50 am, revealed the facility could not produce documentation showing that a 3-year 4-hour exercise of the generator had been performed.

Exit interview with the Administrator on August 2, 2023, at 1:15 pm, confirmed the missing documentation.





Plan of Correction:

Observations #: 0918
Modern Power Group in Bristol Pennsylvania maintains and maintenance the generator for Cornerstone Ambulatory Surgery Center. On August 17,2023 Modern Power will perform the 3-year 4-hour exercise of the generator and provide written documentation.
In accordance with NFPA 101 STANDARD Electrical Systems - Essential Electric System; 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 2040-day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions includes 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). The CASC has included the 3-year 4-hour exercise of the generator within their contract on an annual basis.
The DON will be responsible for monitoring ongoing compliance. This will be discussed at our next staff meeting and will continue to be checked on our preventative Maintenance Checklist and Life Safety checklist.