Initial Comments:
Name - GASTROINTESTINAL ENDOSCOPY CENTER LLC Component - 01
Facility ID# 50491501
Building 01
Main Building
Based on a Relicensure Survey completed on June 7, 2023, it was determined that Gastrointestinal Endoscopy Center, Llc., was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.
This is a one-story, Type V (000), unprotected wood frame construction, which is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
HVAC
Name - GASTROINTESTINAL ENDOSCOPY CENTER LLC Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Based on document review and interview, it was determined the facility failed to maintain and inspect HVAC systems, affecting the entire component.
Findings include:
1. Document review on June 7, 2023, at 8:30 am, revealed the facility could not produce documentation showing that the fire and smoke dampers were tested and exercised within the past 48 months.
Exit interview with the Administrator on June 7, 2023, at 10:00 am, confirmed the lack of documentation.
Plan of Correction:The Fire Alarm Company was contacted and scheduled to test the fire and smoke dampers as required. This was scheduled and completed June 11, 2023. An addendum is being added to the existing contract to ensure the fire dampers are tested every four years hereafter.
Completion of the 4-year Fire Damper testing will be included in the Environment of Care monitoring performed by the DON and was reported to the Patient Safety Committee on 6/27/2023 and will be reported to BOM on 8/23/2023and will be reported annually thereafter.
The BOM, through the Administrator and DON, will ensure that this POC is effective, and compliance is maintained.
NFPA 101 STANDARD
Electrical Systems-Essential Electric System
Name - GASTROINTESTINAL ENDOSCOPY CENTER LLC 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 document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire component.
Findings include:
1. Document review on June 7, 2023, at 8:30 am, revealed the facility could not produce documentation showing monthly testing of battery electrolyte specific gravity or conductance testing of the emergency generator.
Exit interview with the Administrator on June 7, 2023, at 10:00 am, confirmed the lack of documentation.
Plan of Correction:The facility's Generator Maintenance Company was contacted to perform monthly testing of battery electrolyte specific gravity or conductance testing of the emergency generator. An addendum is being added to the existing contract to include monthly testing of battery electrolyte specific gravity or conductance testing.
Testing of battery electrolyte specific gravity or conductance testing of the emergency generator has been scheduled for the maintenance visit on 7/7/2023.
Completion of the monthly testing will be included in the Environment of Care monitoring performed by the DON and reported to the Patient Safety Committee on 8/16/2023 and BOM on 8/23/2023 and annually thereafter.
The BOM, through the Administrator and DON, will ensure that this POC is effective, and compliance is maintained.
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