Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 50361501
Component 01
Main Building
Based on a Relicensure Survey completed on October 30, 2024, at Associates Surgery Centers, LLC, it was determined that the facility was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Healthcare Occupancy.
This is a two-story, Type II (000), unprotected non-combustible building that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING 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 and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting one of two smoke compartments.
Findings include:
1. Observation on October 30, 2024, at 9:55 a.m., revealed data/communication lines supported by the sprinkler line, above the ceiling in the entrance to the stairwell, on the first floor.
Interview with the Interim Facility Administrator and Facility Maintenance Director on October 30, 2024, at 11:30 a.m., confirmed the data/communication lines resting on the sprinkler line.
Plan of Correction:1. Facility Maintenance tech as of 10/31/24 made to necessary repairs to ensure the data line is no longer supported (touching) the sprinkler line.
2. In the future the Director of Nursing will verify that any new cables and/or replacement cable will be not be supported/in communication with the sprinkler line.
3. Will monitor for compliance every month w/ Environmental of Care (EOC) rounds for one (1) quarter until compliance is demonstrated, monitoring will occur for one (1) more consecutive week. Non-compliance will be addressed immediately, repairs will be made, re-education will be instituted; if non-compliance by an employee or provider remains, the discipline process will be implemented.
28 Pa. Code § 569.2 STANDARD
Fire Drills
Name - MAIN BUILDING 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 documentation review and interview, it was determined the facility failed to perform one of four required fire drills, affecting the entire facility.
Findings include:
1. Review of documentation on October 30, 2024, at 8:45 a.m., revealed the facility lacked documentation for the third quarter fire drill.
Interview with the Interim Facility Administrator and Facility Maintenance Director on October 30, 2024, at 11:30 a.m., confirmed the facility lacked documentation for a drill between July and September in 2024.
Plan of Correction:1. Director of Nursing and the Facility Maintenance tech will create a calendar by November 15, 2024, for fire drills to be held on a on a quarterly basis that meets the Department of Health requirements. Director of Nursing and/or the Facility Maintenance tech will conduct these drills and provide a critique, utilizing a critique form.
2. The Director of Nursing will provide a critique form to both Administrator immediately following completion.
3. The Director of Nursing will provide quarterly report to Administrator regarding compliance.
4. Compliance report will be provided to Administrator, Medical Director and Governing Body quarterly as a part of the surgery center's QAPI.
5. Monitor will continue for a calendar year (365 days) until compliance is demonstrated. Once compliance is demonstrated, monitoring will occur for one (1) more consecutive week. Non-compliance will be addressed immediately, re-education will be instituted; if non-compliance by an employee or provider.
|