Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)
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Observations: Name: MAIN - Component: 01 - Tag: 0914
Based on document review and interview, it was determined the facility failed to provide documentation, verifying annual inspections of electrical receptacles, in resident care areas, in two of two smoke zones within the component.
Findings include:
1. Review of documentation on March 29, 2023, between 9:15 AM and 10:40 AM, revealed the facility lacked documentation, verifying electrical receptacles were tested, in the last 12 months.
Interview at the time of the exit conference with the President, Director of Operations, Assistant Director of Facilities Maintenance, Director Regulatory and Accreditation and Maintenance Electrician on March 29, 2023, at 1:15 PM, confirmed the lack of annual electrical inspection documentation.
| | Plan of Correction - To be completed: 04/07/2023
The entire inventory of receptacles at the UPMC Surgery Center were tested on 4/3/23 with appropriate actions taken.
Going forward, receptacle testing for the Surgery Center has been entered into the electronic CMS Facilities Workorder System to generate an annual task. Facilities will generate a workorder for all failed receptacles. The completed receptacle testing report will be filed in the Surgery Center Life Safety Binder. Results of the annual inspection will be reported annually at the Environment of Care Committee meeting.
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