QA Investigation Results

Pennsylvania Department of Health
BEST IMPRESSION SURGICAL CENTER, LLC
Building Inspection Results

BEST IMPRESSION SURGICAL CENTER, LLC
Building Inspection Results For:


There are  22 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 AMBULATORY SURGICAL FACILITY Component - 01

Facility ID # 21531501
Component 01

Based on a Relicensure Survey completed on December 16, 2020, it was determined Best Impression 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 six story, Type II (111), protected non-combustible construction, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Center.






Plan of Correction:




28 Pa. Code 569.2 STANDARD
General Requirements - Other

Name - CLASS C AMBULATORY SURGICAL FACILITY Component - 01
General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.

Observations:

28 Pa. Code 553.3(1) GOVERNING BODY RESPONSIBILITIES

Governing body responsibilities include:

(1) Conforming to applicable Federal, State and local law. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;
Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal, State and local laws and regulations.

Findings include:

1. Observation made on December 16, 2020, at 9:55 am, revealed the facility failed to secure plan approval by the Department of Health prior to installing a Special Locking Arrangement (SLA) on the exit stair near the Supply Room.

Interview at the exit conference with the Director of Nursing on December 16, 2020, at 11:30 am, confirmed the facility failed to obtain Department approved plans prior to installing a Special Locking Arrangement.

28 Pa Code 51.3. Notification (d)





Plan of Correction:

The Director of Nursing has notified the Building Manager that the Special locking Arrangement on the exit stair near supply room needs to be de-activated.

This is not a new SLA for the building, but was de-activated in the past.
The Director of Nursing will check this door monthly to ensure the locking arrangement is De-activated and document on monthly facility checklist.

This will be monitored quarterly in the Patient safety committee.

The Director of Nursing has notified the Building Manager that the hardware on the door that is not operable must be removed.


28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - CLASS C AMBULATORY SURGICAL FACILITY Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on observation, document review and interview, it was determined the facility failed to test and maintain automatic sprinkler components, affecting the entire facility.

Findings include:

1. Document review on December 16, 2020, between 10:00 a.m. and 11:15 a.m., revealed the facility failed to produce fire pump documentation for the following:

a. Annual fire pump testing within the past 12 months;
b. Monthly electric fire pump run for a minimum of 10 minutes.

Interview at the exit conference with the Director of Nursing on December 16, 2020, at 11:30 a.m., confirmed the missing documentation.


2. Document review on December 16, 2020, between 10:00 a.m. and 11:15 a.m., revealed the facility failed to produce documentation demonstrating the mechanical waterflow/alarm devices had been tested quarterly for three of four quarters.

Interview at the exit conference with the Director of Nursing on December 16, 2020, at 11:30 a.m., confirmed the missing documentation.


3. Observation on December 16, 2020, between 9:05 a.m. and 9:20 a.m., revealed external loads on the sprinkler piping, above the ceiling, at the following locations:

a. 9:05 a.m., outside the Electric Room, near the rear entrance to the facility, there was MC and data wire;

b. 9:20 a.m., by the hallway corner, near the Supply Room Entrance, there was fire alarm wiring.

Interview at the exit conference with the Director of Nursing on December 16, 2020, at 11:30 a.m., confirmed the external loads on the sprinkler piping.






Plan of Correction:

The Director of Nursing has notified the Building Manager that the Annual Fire Pump and Sprinkler Tests for the entire Facility is missing vital information on the report that was provided to the ASC.

The Building needs to have the company National Fire Equipment correct the report and include missing information or have the inspection re-done to be in compliance. The report will include the Annual fire pump testing withtin the last 12 months. B) and the monthly electric fire pump run for a minimum of 10 minutes.
3)a External loads on the sprinkler piping above the ceiling near the rear entrance to the facility data wiring will be tied up to ensure it is no touching the sprinkler pipe.
b)the Fire Alarm wiring that was lying on ceiling tile outside supply closet with be tied up.

The DON will add it to the monthly check list and make sure work is complete.


The Director of Nursing will keep records on file in the ASC and will make sure work is completed. Monitoring will be done Quarterly.


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

Name - CLASS C AMBULATORY SURGICAL FACILITY 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 conduct required testing of the emergency generator, affecting the entire component.

Findings include:

1. Document review on December 16, 2020, between 10:00 a.m. and 11:15 a.m., revealed the facility failed to produce documentation demonstrating the monthly conductance testing of the emergency generator batteries for the past 12 months.

Interview at the exit conference with the Director of Nursing on December 16, 2020, at 11:30 a.m., confirmed the missing documentation.






Plan of Correction:

The Director of Nursing will do a monthly Conductance testing of the emergency generator battery.
It will be monitored quarterly at the Patient safety committee.
A record will be kept on file in the ASC.