Initial Comments:Based on an Emergency Preparedness Survey completed on March 25, 2024, at Mid-Atlantic Gastrointestinal Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING Component - 02Facility ID #15891501Component 01 Main Building
Based on a Recertification/Relicensure Survey completed on March 25, 2024, it was determined that Mid-Atlantic Gastrointestinal Center was not in compliance with the following requirements of the Life Safety Code for an new ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).
This is a three-story, Type II (222), fire resistive structure, with a basement, which is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Emergency Lighting
Name - MAIN BUILDING Component - 02
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
Observations:
Based on document review and interview, it was determined the facility failed to provide documentation verifying monthly exercises of battery powered back-up lighting fixtures occurred within the previous twelve months, which serves the entire component.
Findings include:
Review of documentation on March 25, 2024, at 9:51 AM, revealed the facility failed to provide documentation verifying monthly exercises of battery powered back-up emergency lighting fixtures occurred between 8/25/23 and 11/24/23.Interview with the Administrator on March 25, 2024, at 9:51 AM, confirmed the lack of documentation verifying monthly exercises of battery powered back-up emergency lighting fixtures occurred, within the previous twelve months.
Plan of Correction:K 0291 NFPA 101 Emergency Lighting .
MONTHLY REPORTS
SYSTEMIC CHANGES
All available 2024 Monthly Emergency Lighting Battery testing reports were obtained from facilities management and reviewed for completeness 4/9/2024. CA to review Monthly Emergency Lighting Battery testing report for completeness and retain the report in the facility EOC binder.
MONITORING AND SUSTAINING THE PLAN The CA will obtain the Emergency Lighting Battery testing report monthly and will document this on the EOC checklist to monitor for 100% compliance. Moving forward the EOC monthly checklist will be marked as completed once reports are obtained and verified as complete by the CA.
RESPONSIBLE PARTY AND REPORTING
The CA is responsible to implement the changes identified in this POC.
The CA will provide results of this survey, the corrective actions, and results from monitoring to the Quality Assurance Improvement Committee quarterly for review and recommendations.
Recommendations will be submitted to the Governing Board for review and approval.
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - MAIN BUILDING Component - 02
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 provide documentation verifying the quality of the fuel reserve for the emergency generator was acceptable for use, which serves the entire component.
Findings include:
Review of documentation on March 25, 2024, at 10:10 AM, revealed the emergency generator fuel analysis report completed on June 26, 2023, resulted in a failure of the fuel for high distillation values. The facility failed to provide documentation verifying corrective action was taken after the failure of the diesel fuel reserve.Interview with the Administrator on March 25, 2024, at 10:10 AM, confirmed the lack of documentation verifying the fuel reserve for the emergency generator was acceptable for use.
Plan of Correction:K 0918
NFPA 101 Electrical Systems
GENERATOR FUEL ANALYSIS
.SYSTEMIC CHANGES
Generator fuel analysis is scheduled to be done on 4/16/2024. CA to review report once received for any further action. If indicated per the report, CA will collaborate with Generator contractor and Fuel supplier to ensure diesel fuel is acceptable for use.
MONITORING AND .SUSTAINING THE PLAN
The CA will confirm the report has been received and any actionable findings are reported to the Governing Body. The CA or designee will schedule the generator fuel analysis on an annual basis and reports will be stored in the Environment of Care binder for tracking purposes.
RESPONSIBLE PARTY AND .REPORTING
The CA is responsible to implement the changes identified in this POC.
The CA will provide results of this survey, the corrective actions, and results from monitoring to the Quality Assurance Improvement Committee quarterly for review and recommendations.
Recommendations will be submitted to the Governing Board for review and approval.
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