Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID #10621500
Component 01
Main Building
Based on a Relicensure Survey completed on December 12, 2023, it was determined that Valley View Surgical Center Llc was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a one-story, Type V (000), unprotected wood frame structure, without a basement, which is not sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Testing and Maintenance
Name - MAIN BUILDING 01 Component - 01
Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5
Observations:
Based on document review and interview, it was determined the facility failed to provide verification that the annual, semiannual and 2-year sensitivity inspection had been performed, affecting the entire component.
Findings include:
1. Review of documentation on December 12, 2023, between 8:45 AM and 9:30 AM, revealed the facility lacked documentation, verifying the fire alarm system had an annual functional and semiannual visual inspection, in the last twelve months.
Interview with the Administrator on December 12, 2023, at 12:30 PM, confirmed the lack of documentation for any fire alarm inspections, in the last twelve months.
2. Review of documentation on December 12, 2023, between 8:45 AM and 9:30 AM, revealed the facility failed to provide documentation, verifying the sensitivity of smoke detectors installed, throughout the facility, had been tested, in the past two years.
Interview with the Administrator on December 12, 2023, at 12:30 PM, confirmed the lack of documentation, verifying the sensitivity of smoke detectors installed, throughout the facility, had been tested, in the previous two years.
Plan of Correction:Upon realization of the lack of documentation, Fitz Security Company was contacted and came on-site, 12/12/23, to perform the annual and 2-year sensitivity inspection. Our systems were found to be in good working order and a copy of the report was sent to the inspector.
However, the report did not fully list each unit inspected or the sensitivity range of the detectors. Fitz was contacted again and will be updating the documentation to include the necessary information by 1/31/2024.
It was also communicated and agreed upon that Fitz Security would be out in June of 2024 to perform the semi-annual visual inspection and October of 2024 to perform the annual inspection.
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - MAIN BUILDING 01 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 periodic testing of the generator, affecting the entire component.
Findings include:
1. Review of documentation on December 12, 2023, between 8:45 AM and 9:30 AM, revealed the facility lacked documentation, verifying a continuous 4-hour exercise of the emergency generator, within the past 36 months.
Interview with the Administrator on December 12, 2023, at 12:30 PM, confirmed the facility could not provide documentation that the 3-year test had been performed.
Plan of Correction:Power Systems Electric, the company that performs the generator inspections for the facility, was contacted about performing a 4-hour exercise of the emergency generator. Power Systems Electric advised us on the appropriate procedure to perform and then document the exercise, which will be completed by 1/31/2023. Upon completion of the 4-hour exercise, we will schedule out a time/date within the coming 36 months to perform the exercise again and maintain compliance.
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