Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 05801500
Component 01
Main building
Based on a Relicensure Survey completed on August 3, 2023, it was determined that Shadyside Surgi-Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 28 Pa Code 569.2.
This is a two-story, Type II (111), protected non-combustible building, without a basement, that is not sprinklered. The ASC is located on the first floor.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - MAIN BUILDING 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 documentation review and interview, it was determined the facility failed to maintain the emergency generator in four instances, affecting the entire facility.
Findings include:
1. Review of documentation on August 3, 2023, at 8:30 a.m., revealed the facility lacked documentation for the following required emergency generator maintenance and testing:
a) Weekly battery electrolyte levels or battery voltage testing;
b) Monthly electrolyte specific gravity or conductance testing;
c) Monthly operation of transfer switch;
d) Three year 4-hour load test.
Interview with the Facility Administrator on August 3, 2023, at 9:30 a.m., confirmed the facility lacked the emergency generator maintenance and testing documentation, at the time of the survey.
**** Note: During the revisit on October 16, 2023, between 8:30 a.m., and 9:30 a.m., it was revealed that number 1 was not complete.
Interview with the Facility Administrator on October 16, 2023, at 9:30 a.m., confirmed the facility lacked the emergency generator maintenance and testing documentation, at the time of the survey.
Plan of Correction:The Weekly and Monthly Generator Maintenance policy will be amended to include the need for the following generator maintenance and documentation: Weekly battery electrolyte levels or battery voltage testing; Monthly electrolyte specific gravity or conductance testing; Monthly operation of transfer switch; Three year 4-hour load test. The weekly and monthly generator maintenance logs will also be updated so that this information can be documented by the Surgi-Center director of nursing per the policy. The completion and documentation of this testing will be monitored by the Facility Director and compliance will be reported as a part of the Quality Assurance meetings quarterly. Surgi-Center staff will meet with the contracted generator maintenance service provider to ensure understanding of this testing and all policy updates will be completed by November 3, 2023. Curtis Power, our contracted generator service provider, is scheduled to visit November 3, 2023 to conduct the four hour load test and provide the education to staff for routine checks.
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