Pennsylvania Department of Health
PROGRESSIVE SURGICAL INSTITUTE, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PROGRESSIVE SURGICAL INSTITUTE, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #09891500
Component 01
Building 01

Based on a Relicensure Survey completed on October 30, 2024, it was determined that Progressive Surgical Institute 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 structure which is partially sprinklered.

Plan of Correction:

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

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:
Name: MAIN BUILDING - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to provide documentation verifying the emergency generator had been exercised monthly, under load, for a minimum of 30 minutes, affecting the entire component.

Findings include:

1. Review of documentation on October 30, 2024, at 11:00 AM, revealed the facility failed to provide documentation verifying the emergency generator was exercised, under load, for a minimum of 30 minutes, in the month of April, 2024.

Interview with the Director of Nursing, on October 30, 2024, at 11:00 AM, confirmed the lack of documentation verifying the emergency generator had been exercised monthly, under load, for a minimum of 30 minutes.

Plan of Correction - To be completed: 11/01/2024

Corrective Action: The ASF has updated its generator testing log to include a 30 minute run time section. Staff who perform the generator monthly testing have been reeducated on the requirement of the 30 minute load test and proper documentation of the updated log.

Responsible Party: Administrator

Monitoring: The Administrator will review the monthly generator logs for compliance and bring the results to the quarterly QAPI meetings. Any deviations will be reported to the Governing Board.

28 Pa. Code § 569.2 STANDARD Electrical Equipment - Power Cords:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to monitor the use of receptacle multipliers, affecting the entire component.

Findings include:

1. Observation on October 30, 2024, at 11:40 AM, revealed a three-to-one receptacle multiplier in use, in the Equipment Storage Room.

Interview with the Director of Nursing on October 30, 2024, at 11:40 AM, confirmed the use of a receptacle multiplier.

Plan of Correction - To be completed: 11/01/2024

Corrective Action: The power strips were removed immediately from use on the day of the survey. The Center's environmental rounding tool has been updated to include compliance or non-compliance with the use of power strips/cords. Center staff have been re-educated on not using power strips in patient care areas.

Responsible party: Administrator

Monitoring: The Administrator will review the environmental rounding tool on a monthly basis and report findings to the QAPI Committee during their quarterly meetings. Any deviations will be reported to the Governing Board.

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