Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 79921500
Component 01
Main Building
Based on a Relicensure Survey completed on August 31, 2023, it was determined that Southwestern Pennsylvania Eye Surgery Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a one-story, Type V (000), unprotected wood frame building, with a basement, that is not sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Emergency Lighting
Name - MAIN BUILDING 01 Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
Observations:
Based on document review and interview, it was determined the facility failed to maintain emergency lighting in one instance, affecting the entire facility.
Findings include:
1. Documentation review on August 31, 2023, at 8:30 a.m., revealed the facility lacked documentation for an annual 90-minute test for the emergency lights.
Interview with the Clinical Director on August 31, 2023, at 8:30 a.m. confirmed the facility lacked documentation for the annual 90-minute test for the emergency lights at the time of survey.
Plan of Correction:PFE Fire and Safety Corporation failed to document on their report that an annual 90-minute test for the emergency lights was completed. PFE was contacted and an updated report was received that states that the annual 90-minute test for the emergency lights was completed on May 12, 2023. PFE was asked to add this documentation to the annual inspection report moving forward.
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