QA Investigation Results

Pennsylvania Department of Health
ALLEGHENY SURGERY CENTER, LLC
Building Inspection Results

ALLEGHENY SURGERY CENTER, LLC
Building Inspection Results For:


There are  26 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - AREA D Component - 01
Facility ID# 17691501
Component 01
Main Building

Based on a Relicensure Survey completed on November 7, 2023, it was determined that Allegheny Surgery Center LLC was not in compliance with the following requirements of the Life Safety Code for a existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).

This is a one-story, Type II (000), unprotected non-combustible building, without basement, that is fully sprinklered.





Plan of Correction:




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

Name - AREA D 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 documentation review and interview, it was determined the facility failed to maintain the automatic transfer switch, in one instance, affecting the entire facility. Testing shall be accordance with NFPA 110, 8.4.6. and NFPA 101 7.9.1.3.

Findings include:

1. Review of documentation on November 7, 2023, at 9:45 a.m., revealed the facility lacked documentation confirming the monthly testing/function of the automatic transfer switch, that a delay of not more than ten seconds shall be permitted to emergency power.

Interview with the Facility Administrator and Facility Staff on November 7, 2023, at 12:30 p.m., confirmed the automatic transfer switch, testing deficiency.





Plan of Correction:

Plan Of Correction # 0918
Electrical Systems-Essential Electric System

1. The systematic change that will be put into place to ensure that the deficiency does not recur include re-education of the maintenance staff regarding documentation requirements that include notation of the time confirming the monthly testing and function of the automatic transfer switch. Additionally reviewed that a delay of no more than 10 seconds was acceptable.
Additionally, the generator testing form was revised to make the documentation of the transfer switch function more precise, and the timed component was added. Both the re-education and the form revisions were completed on 11-7-2023.
Monitoring of the form and testing compliance will be done each month following testing of the generator after maintenance completes the generator check and submits the form to the facility. The form will at that time be reviewed for accuracy and completeness.
Any non-compliance will be immediately addressed.

2. The Quality Assurance Program that will be put into place to assure continued compliance with the plan of correction will include reviewing compliance @ each of the next 3 quarterly Quality Improvement Meetings.