Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID# 16701501
Component 01
Main Building
Based on a Relicensure Survey completed on August 16, 2023, it was determined that Main Line Endoscopy Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a nine story, Type II (000), unprotected, noncombustible building, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Testing and Maintenance
Name - CLASS B ASF 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 maintain and inspect the fire alarm system, affecting the entire component.
Findings include:
1. Document review on August 16, 2023, at 8:15 am, revealed the facility could not provide documentation of a semi-annual visual fire alarm inspection within 6 months of May 5, 2023.
Exit interview with the Administrator and Director of Nursing on August 16, 2023, at 9:30 am, confirmed the lack of documentation.
Plan of Correction:The Center Administrator notified the Medical Director and Governing Board of the preliminary findings from the agency visit on 8/16/2023.
Fire Alarm System - Testing and Maintenance NFPA 70 National Electric Code and NFPA 72 National Fire Alarm and Signaling Code SO345
Systemic Changes
The Center Administrator contacted the building manager responsible for scheduling the fire alarm system vendor for inspections. The vendor was contacted to schedule the semi-annual fire alarm visual inspection on 10/3/2023. The Center Administrator will verify inspection documents with the building manager and vendor, prior to the vendor exit, to confirm that the inspection was completed.
Monitoring and Sustaining the Plan
The inspection is completed, the Center Administrator will place a reminder on the calendar to contact the vendor no less than 30 days prior to the next inspection due date.
Responsible Party and Reporting
The Center Administrator is responsible for compliance with the content of this Plan of Correction.
Documentation of compliance is reported to and reviewed by the Quality Assessment and Performance Improvement (QAPI) and Medical Executive Committee (MEC) Committees. Minutes from QAPI/ MEC Committee meetings will serve as a validation that the groups were informed, and that the systemic changes addressed here were recommended to the Governing Board for approval at the next scheduled meeting.
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