Initial Comments:
Name - BERKS CENTER FOR DIGESTIVE HEALTH, LLC MAIN BUILDI Component - 10
Facility ID# 15491501
Component 10
Main Building
Based on a Relicensure Survey completed on September 22, 2020, it was determined that Berks Center for Digestive Health, L.P. 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 II (000), unprotected noncombustible structure, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - BERKS CENTER FOR DIGESTIVE HEALTH, LLC MAIN BUILDI Component - 10
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 observation and interview, the facility failed to provide a remote stop outside the generator enclosure for the emergency generator, which supplies power to the component.
Findings include:
1. Observations on September 22, 2020, at 11:00 AM revealed the required remote manual stop station, for the generator, had not been installed. NFPA 110 - 3.5.5.6
Interview with the Administrator on September 22, 2020, at 11:00 AM confirmed the switch had not been installed.
Plan of Correction:The facility's BOM was made aware of this finding on 9/24/20 and it has given approval for the immediate installation of a remote emergency stop switch, in accordance with Pa. Code § 569.2. On 9/24/20, the administrator requested quotes for installation of a generator remote stop switch to be located outside of the generator enclosure. This emergency stop button will be placed within the facility and will be in an unlocked location that is readily accessible. Completion date for the installation of this emergency stop button is expected by end of 11/15/2020, at which time all staff will be educated on its intended use. All staff will be trained on operating the emergency stop button as well as when it should be utilized.
To ensure this Plan of Correction (PoC) is sustained, the emergency stop switch will be inspected weekly as part of the Environment of Care (EOC) rounds and included in the scheduled maintenance and testing of the generator.
The administrator and DON will be responsible in implementing this PoC.
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