QA Investigation Results

Pennsylvania Department of Health
BUCKS COUNTY SURGICAL SUITES
Building Inspection Results

BUCKS COUNTY SURGICAL SUITES
Building Inspection Results For:


There are  7 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - CLASS C - FIRST FLOOR TENANT SPACE Component - 01

Facility ID# 50511501
Component 01

Based on a Relicensure Survey completed on October 4, 2023, it was determined that Bucks County Surgical Suites was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.

This is a three-story, Type II (000), unprotected non-combustible construction, which is fully sprinklered.




Plan of Correction:




NFPA 101 STANDARD
Electrical Systems - Maintenance and Testing

Name - CLASS C - FIRST FLOOR TENANT SPACE Component - 01
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)

Observations:

Based on document review and interview, it was determined the facility failed to maintain receptacle testing/inspection in patient care rooms at bed locations, affecting the entire facility.

Findings include:

1. Document review on October 4, 2023, at 9:30 am, revealed annual receptacle testing conducted in September 2023 found 12- receptacles deficient. The receptacles remained uncorrected at that time of survey.

Exit interview with the Administrator on October 4, 2023, at 10:45 am, confirmed the receptacle conditions.





Plan of Correction:

Annual Inspection performed on 9.29.2023, and reported to facility on 10.2.2023. Inspection on 10.4.2023. The electrical contractor was contacted and service requested upon receipt of the deficiency report from biomedical testing. Items for replacing ordered, and the work was performed on 10.19.2023. Components retested on 10.24.2023 by biomedical engineer, and all deficiencies are recorded as corrected and passing.

Annual testing dates have been moved to the spring to allow time for corrections to be made prior to survey.

All testing and survey reports are reviewed during quarterly meetings.


NFPA 101 STANDARD
Electrical Systems-Essential Electric System

Name - CLASS C - FIRST FLOOR TENANT SPACE Component - 01
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 maintain required testing of emergency generator components, affecting one generator.

Findings Include:

1. Document review on October 4, 2023, at 9:50 am, revealed documentation showing monthly conductance testing of the emergency generator's sealed battery was not available at the time of survey.

Exit interview with the Administrator on October 4, 2023, at 10:45 am, confirmed the missing documentation.





Plan of Correction:

Upon notification of deficiency, a Topdon BT600 battery tester was purchased. The monthly generator load test form has been updated to include the battery charge percentage, battery voltage, battery health level, and measured CCA for both batteries individually, and across both batteries together.

The batteries are tested monthly during the generator load test with the power supply for the battery charger disconnected, and results documented on the load test form. Monthly generator testing and outcomes are reported quarterly during executive meetings.