QA Investigation Results

Pennsylvania Department of Health
BRANDYWINE SURGERY CENTER
Building Inspection Results

BRANDYWINE SURGERY CENTER
Building Inspection Results For:


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Initial Comments:
Name - CLASS C ASF Component - 01

Facility ID: 16621501
Component 01
Main Building

Based on a Relicensure Survey completed on January 8, 2019, it was determined that Brandywine Surgery Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

The is a two-story, Type III (200), unprotected ordinary structure, which is fully sprinklered above and below the ceiling.

Approved as a Class C Ambulatory Surgical Facility.





Plan of Correction:




28 Pa. Code 569.2 STANDARD
Multiple Occupancies

Name - CLASS C ASF Component - 01
Multiple Occupancies - Sections of Ambulatory Health Care Facilities
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following:
* The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access.
* They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating.
Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following:
* Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab.
* Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches.
* Doors are self-closing and are kept in the closed position, except when in use.
* Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44

Observations:

Based on observation and interview, it was determined the facility failed to maintain the one-hour fire resistant tenant separation wall.

Findings Include:

1. Observation made on January 8, 2019, at 1:25 pm, revealed that the waiting area tenant separation entrance doors failed to close smoke tight into the corresponding door frame assembly when tested.

Interview with the Administrator on January 8, 2019, at 2:15 pm, confirmed doors would not resist the passage of smoke.







Plan of Correction:

The Brandywine Surgery Center will correct this deficiency adjusting the door handle and adding trim to fill the space between the 2 doors thereby allowing the doors to close smoke tight into the corresponding door frame assembly and resist the passage of smoke. The building manager has already been contacted to help arrange this correction. This administrator will include this door on monthly rounds checking for proper door closure. The Governing Body of Brandywine Surgery Center will review at the Quality Assurance Committee Meetings that the above measures are complete and ongoing. The Administrator/CEO will attest to completion by 2/28/19


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

Name - CLASS C ASF 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 observation and interview, it was determined the facility failed to maintain all components of the emergency generator in operable condition, affecting the entire facility.

Findings include:

1. Observation made on January 8, 2019, at 1:40 pm, revealed that the emergency generator annunciator panel, lamp test button, failed to illuminate when tested, located at the nurses station.

Interview with the Administrator on January 8, 2019, at 2:15 pm, confirmed that the generator components were not maintained properly.






Plan of Correction:

The Brandywine Surgery Center will correct this deficiency by replacing the Annuciator panel. This was completed 1/25/19. Monitoring of The Annunciator panel is done by the following:
It is in the nurses station and next to the locker room. It is continuously monitored by staff while the OR is in use. The annunciator panel will be continuously monitored visually by a camera. The monitor for the camera is in the administrators office on the desk which is a continuously manned location. The administrator can visualize the annunciator panel at all times during each day of business operation.
3 times a day(8am,12pm and 4pm) the administrator will physically walk to the nurses station to check the panel. The audible alarm is loud enough to be heard throughout the facility(by everyone)on any given day. In the absence of the administrator a designated employee, the managers assistant will be given this duty. A new policy will be created regarding the above monitoring of the annunciator panel. The Governing Body will ensure the completion of this correction. The Quality Assurance Committee will also monitor completion annually and the safety Committee will review compliance quarterly. The staff has been educated on the annunciator panel.
Corrective action will occur by 2/28/19.
The CEO/Administrator will attest to completion by 3/28/19.



28 Pa. Code 569.2 STANDARD
Electrical Equipment - Testing/Maintenance

Name - CLASS C ASF Component - 01
Electrical Equipment - Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Observations:

Based on document review and interview, it was determined the facility failed to maintain required testing of electrical receptacles, affecting patient bed locations.

Findings include:

1. Documentation reviewed on January 8, 2019, between 8:30 a.m. and 10:45 a.m., revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and for hospital grade receptacles based on documented performance data or, minimally not exceeding 12 months. Receptacle testing should include the following:

a. resident care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall be not less than 115g (4 oz).

Interview with the Administrator on January 8, 2019, at 2:15 pm, confirmed testing of electrical receptacles was not provided.





Plan of Correction:

The Brandywine Surgery Center will correct this deficiency by contacting Red Lion for testing of the electrical outlets.
The receptacles will be checked at the patient bed location where deep sedation or general anesthesia is administered.
Receptacle testing will include resident care rooms, visual inspection of physical integrity, correct polarity of the hot and neutral connections and retention force of the grounding blade shall be not less than exceed 115g.
This deficiency has been corrected. Red Lion has checked all appropriate outlets. Compliance will be assured by the Quality Assurance Committee.
The required testing of electrical outlets has been added to Red Lions annual Bio Med testing of the BSC.
Corrective action will be ensured by 2/28/19. The CEO/Administrator will attest to completion by 2/28/19.