This report is the result of a State licensure survey conducted on February 19, 2021, at Ambulatory Surgery Center - Jefferson Pain and Rehab Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.
Plan of Correction:
Testing Fire Warning Systems
Name - Component - 00
569.13 Testing Fire Warning Systems
Fire safety systems, including automatic fire extinguishing systems,
automatic and manual alarms, stand pipes and hose reels shall be of an
approved type. They shall be kept in good operating condition and inspected
by qualified ASF personnel at least every 3 months. Records of the
inspections shall be kept on file for the licensure period.
Based on a review of facility policy and procedure and staff interview (EMP), it was determined that the facility failed to inspect the fire safety systems, including automatic fire extinguishing systems, automatic and manual alarms, stand pipes and hose reels every three months by a qualified ASF personnel.
Review of facility policy "Fire Safety" last revised February 2020, revealed "...Tests and Inspections: ... 2. Fire alarm systems will be maintained in a safe, operable condition in accordance with NFPA 70 and 99 and will be inspected bi-annually."
1) Review of facility documents revealed documentation of inspecting fire safety systems, automatic fire extinguishing systems, automatic and manual alarms, stand pipes and hose reels on January 24, 2020, July 13, 2020, and January 21, 2021. Inspections were not documented for April 2020, or October 2020.
2) Interview with EMP1 on February 19, 2018, at approximately 12:15 PM confirmed the above findings.
Plan of Correction:
The Safety Director will oversee and verify that the inspection of the fire safety systems will be implemented on a quarterly basis. The inspections will be done by I.E.S. in the first and third quarters of each year. The Safety Director will then conduct the inspections in the second and fourth quarters of each year, which will include the testing of the fire alarm system. The Safety Director will maintain records for each quarterly test. The policy for Fire and Safety, Reference # 8015, has been updated to reflect the quarterly requirement of the inspection of the fire safety system.