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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MONTGOMERY SURGERY CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: CLASS C ASF - Component: 01 - Tag: 0000

Facility ID# 15231501
Component 01
Main Building

Based on a Relicensure Survey completed on January 25, 2024, it was determined that Montgomery Surgery Center, LLC was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a two-story, Type III (200), unprotected ordinary building, with a basement, that is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Electrical Systems - Other:

Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.

Observations:
Name: CLASS C ASF - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of three levels.

Findings include:

Observation on January 25, 2024, at 10:50 a.m., revealed multiple missing circuit breaker protective blanks, electrical panel basement electrical room.

Exit interview with the Administrator on January 25, 2024, at 11:00 a.m., confirmed the missing protective covers.

~Refer to 2011 edition of NFPA 70-314.28.

Plan of Correction - To be completed: 03/09/2024

Center hired electrician to place protective blanks in all open circuit breaker slots on the electrical panel in the basement electrical room. Work was completed 02/12/2024. Facility manager was instructed to monitor all electrical panels to assure that this does not occur again in the future. DON will check panels quarterly going forward starting 03/01/2024.

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: CLASS C ASF - Component: 01 - Tag: 0918

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting one generator.

Findings include:

Document review on January 25, 2024, at 9:30 a.m., revealed annual fuel quality test results for the emergency generator diesel fuel were not available for review at time of survey.

Exit interview with the Administrator on January 25, 2024, at 11:00 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 03/19/2024

DON reviewed current contract with generator maintenance vendor to find that full fuel testing was not included with the lube oil and coolant analyses done during the full PM service annually. DON contacted vendor on 02/15/2024 to make sure this was added to our service to be done every year. DON scheduled a fuel test to be completed as soon as vendor is able. Fuel testing was added to DON yearly agenda checklist to assure that it is completed every year.

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