Initial Comments:
Name - ASF Component - 01
Facility ID # 15821501
Component 01
Main Building
Based on a Relicensure Survey conducted on September 11, 2023, it was determined that UPMC Altoona Surgery Center 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 building, with a basement, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Hazardous Areas - Enclosure
Name - ASF Component - 01
Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7
Observations:
Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in two instances, affecting two of three smoke compartments.
Findings include:
1. Observation on September 11, 2023, revealed the facility failed to maintain the required one-hour fire rating in the following hazardous area enclosures:
a) 10:55 a.m., an above ceiling inspection in the hallway outside the clean utility room door 265 A revealed an unsealed wire penetration in the hazardous area enclosure wall;
b) 11:19 a.m., there were unsealed data wires inside the sterile tank room above the entrance door and above the tank on the rear wall.
Interview with the Facility Staff on September 11, 2023, at 11:30 a.m., confirmed the above listed hazardous area enclosure deficiencies.
Plan of Correction:Both wire penetrations, above door 265A and above the Sterile Tank Room entrance door, were sealed with the appropriate fire-proof caulking prior to the completion of the inspection on September 11, 2023. Spot checks of fire wall penetrations will be conducted on a semi-annual basis to ensure proper coverage.
28 Pa. Code § 569.2 STANDARD
Electrical Systems - Maintenance and Testing
Name - ASF 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 documentation review and interview, it was determined that the facility failed to maintain electrical receptacles in patient bed locations and in locations where sedation and general anesthesia is administered, in accordance with NFPA 99, 2012 edition, 6.3.4.1.3
Findings include:
1. Documentation review on September 11, 2023, at 9:00 a.m., revealed the facility lacked documentation for an annual electrical receptacle inspection in patient bed locations and in locations where sedation and general anesthesia is administered.
Interview with Facility Staff on September 11, 2023, at 11:30 a.m., confirmed the facility lacked documentation for the required annual electrical receptacle inspection performed within the last 12 months.
Plan of Correction:To ensure electrical receptacle are inspected in patient bed locations and in locations where sedation and general anesthesia is administered, the facilities director will develop an annual preventative maintenance monitor. The 2023 preventative maintenance for the surgery center will be completed by October 31, 2023.
28 Pa. Code § 569.2 STANDARD
Electrical Equipment - Power Cords
Name - ASF Component - 01
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of three smoke compartments.
Findings include:
1. Observation on September 11, 2023, at 11:20 a.m., revealed a coffee maker and refrigerator was plugged into a power strip in the Medical Directors office.
Interview with the Facility Staff on September 11, 2023, at 11:30 a.m., confirmed the above listed electrical wiring systems and equipment deficiency.
Plan of Correction:The power strip identified in the Medical Director's office was removed and discarded prior to the completion of the inspection on September 11, 2023. Additionally, education was provided to staff at the Surgery Center on the safety implications of using power strips in appropriately to promote ongoing compliance. The manager of environmental health and safety conducts an annual safety inspection of the surgery center and will identify noncompliance during this inspection. Noncompliance will be documented and reported to the appropriate member of leadership to provide education and guidance.
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