Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID# 23631501
Component 01
Main Building
Based on a Relicensure Survey completed on November 9, 2022, it was determined Crozer Endoscopy Center (a Department of Crozer Chester Medical Center) was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a three story, Type II (000), unprotected, noncombustible construction, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Evacuation and Relocation Plan
Name - CLASS B ASF Component - 01
Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 20/21.7.2.1.2 and provides for all of the fire safety plan components per 20/21.7.2.2.
20.7.1.1 through 20.7.1.3, 20.7.1.8 through 20.7.2.3.3
21.7.1.1 through 20.7.1.3, 21.7.1.8 through 20.7.2.3.3
Observations:
Based on document review and interview, it was determined the facility could not produce an evacuation and relocation plan, affecting the entire component.
Findings include:
1. Document review on November 9, 2022, at 8:15 a.m., revealed the facility could not produce an evacuation and relocation plan.
Exit interview with the Director of Facilities and Facilities Manager on November 9, 2022, at 9:30 a.m., confirmed the lack of documentation.
Plan of Correction:The Director of Facilities located the Evacuation Policy after the conclusion of the survey. This Fire Safety policy will be reviewed and updated by the Director of Facilities and uploaded to the health system's policy software, PolicyTech, by 12/23/22.
This policy will be updated by the Director of Facilities or a designee annually, or sooner when changes are needed, moving forward. The policy has also been added to the Facilities Department inspection book.
The Director of Facilities is ultimately responsible for this plan of correction.
28 Pa. Code § 569.2 STANDARD
Fire Drills
Name - CLASS B ASF Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7
Observations:
Based on document review and interview, it was determined the facility did not properly conduct fire drills, affecting the entire component.
Findings include:
1. Document review on November 9, 2022, at 8:15 a.m., revealed the facility could not produce documentation fire drills were conducted on a quarterly basis.
Exit interview with the Director of Facilities and Facilities Manager on November 9, 2022, at 9:30 a.m., confirmed the lack of documentation.
Plan of Correction:The Director of Facilities will conduct a fire drill and complete staff fire education for Crozer Endoscopy Center at Brinton Lake by 12/23/22.
Subsequent quarterly fire drills will be scheduled in February, May, August and November of 2023. These drills will be conducted by the Director of Facilities or a designee.
The Director of Facilities is ultimately responsible for this plan of correction.
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