Initial Comments:
Name - PINNACLE HEALTH OUTPATIENT HLTH CTR-AMB. SURG CTR Component - 01
Facility ID#12371500
Component 01
Main Building
Based on a Relicensure Survey completed on August 24, 2023, it was determined that West Shore Surgery Center, Ltd. was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.
This is a two-story, Type II(000), unprotected noncombustible structure, with a basement, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - PINNACLE HEALTH OUTPATIENT HLTH CTR-AMB. SURG CTR Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on document review and interview, it was determined the facility failed to provide quarterly and semi-annual and sprinkler maintenance documentation, affecting the entire component.
Findings include:
1. Review of documentation on August 24, 2023, between 8:15 AM and 10:00 AM, revealed the facility lacked documentation, for the following:
a. 8:25 AM. Wet System, semi-annual, Valve Supervisory Switches and Pressure Switch Waterflow Alarm;
b. 8:30 AM, quarterly 3rd and 4th, Wet Inspections.
Interview with the Facilities Manager on August 24, 2023, at 12:45 PM, confirmed the lack of documentation for Wet Sprinkler systems.
Plan of Correction:The citation is for failure to provide documented evidence of wet sprinkler systems inspections. After careful investigation and review it was determined the documentation for the completed wet sprinkler systems inspections were sent to individuals no longer employed by our health system. Facilities has contacted the contracted vendor to ensure all proper contacts have been corrected. Updated documentation supporting the citing has been provided and logged in compliance binders, as well as provided to the administrator of West Shore Surgical Center. The facilities site manager will perform quarterly reviews of all documentation to ensure that they are up to date for this location.
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