Pennsylvania Department of Health
JEFFERSON SURGICAL CENTER
Building Inspection Results

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JEFFERSON SURGICAL CENTER
Inspection Results For:

There are  10 surveys for this facility. Please select a date to view the survey results.

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JEFFERSON SURGICAL CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: JEFFERESON SURGICAL CENTER - Component: 01 - Tag: 0000


Facility ID# 24681501
Component 01

Based on a Relicensure Survey completed on April 2, 2024, it was determined that Jefferson Surgical Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is an eight story, Type II (222) fire resistive building, with a basement and mechanical penthouse, that is fully sprinklered.





 Plan of Correction:


28 Pa. Code 569.2 STANDARD Electrical Systems -Essential Electric System:State only Deficiency.
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: JEFFERESON SURGICAL CENTER - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

Document review on April 2, 2024, at 8:15 a.m., revealed the facility could not produce documentation of monthly battery conductance testing.

Exit interview with the Maintenance Director and the Administrator on April 2, 2024, at 9:45 a.m., confirmed the lack of documentation.



 Plan of Correction - To be completed: 04/26/2024

Beginning 4/24/24, the facility will test the battery conductance weekly until the batteries can be replaced with maintenance-free, sealed batteries. Battery bank replacement is anticipated to occur on or before May 31,2024. The new battery bank will be commissioned with a generator test.

The building supervisor will report weekly testing results to the Associate Director of Facilities, beginning the week of 4/22/24 and continuing until the relocation of the Jefferson Surgical Center. This move is anticipated to occur in May 2024. Additionally, the weekly testing results will be reported at the June Environment of Care Committee meeting.

The Associate Director of Facilities will ensure the completion of this plan of correction.


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