QA Investigation Results

Pennsylvania Department of Health
BRANDYWINE SURGERY CENTER
Building Inspection Results

BRANDYWINE SURGERY CENTER
Building Inspection Results For:


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Initial Comments:
Name - CLASS C ASF Component - 01

Facility ID# 16621501
Component 01
Main Building

Based on a Relicensure Survey completed on January 27, 2022, it was determined Brandywine Surgery Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory Health Care Occupancy.

The is a two-story, Type III (200), unprotected ordinary structure, which is fully sprinklered above and below the ceiling.

Approved as a Class C Ambulatory Surgical Facility.




Plan of Correction:




28 Pa. Code 569.2 STANDARD
Fire Alarm System - Out of Service

Name - CLASS C ASF Component - 01
Fire Alarm - Out of Service
Fire alarms that are out of service for 4 hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

Observations:

Based on document review and interview, it was determined the facility failed to maintain required policies for the fire alarm system, affecting the entire facility.

Findings include:

1. Document review on January 27, 2022, at 8:15 a.m., revealed the facility did not have a fire watch policy to implement in the event the required fire alarm system was out of service for more than four hours in a 24-hour period.

Exit Interview with the Administrator on January 27, 2022, at 9:45 a.m., confirmed the lack of documentation.





Plan of Correction:

The Brandywine Surgery will correct this deficiency by the following:
1. Create a Fire Watch Policy to implement in the event the required fire alarm system was out of service for more than four hours in a 24hr period.
2. After completion of the above the Governing Body will meet to review and approve the new policy.
3. When the new policy is approved the staff will be educated on the new Policy
4. Monitoring of the new policy will be done quarterly by the Safety Committee and reviewed annually by the Governing Body.
The corrective action will be completed by 3/14/2022. CEO/Administrator will attest to completion of this task


28 Pa. Code 569.2 STANDARD
Electrical Systems -Essential Electric System

Name - CLASS C ASF 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 the generator, affecting the entire facility.

Findings include:

1. Document review on January 27, 2022, at 8:15 a.m., revealed the facility could not produce documentation an annual fuel quality test had been performed.

Exit Interview with the Administrator on January 27, 2022, at 9:45 a.m., confirmed the lack of documentation.





Plan of Correction:

The Brandywine Surgery Center will correct this deficiency by the following:
1. Add the annual fuel quality test to the Cummins contract.
2. The Safety committee will assure completion of this task.
3. Annually, The QA committee will assure completion of this task.
The corrective action will be completed by 3/14/22. o
CEO/Administrator will attest to completion of this task.