Initial Comments:
Name - MAIN BUILDING Component - 02
Facility ID# 17291501
Component 02
Main Building
Based on a Relicensure Survey completed on September 20, 2023, it was determined that Southwestern Endoscopy Center was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).
This is a one-story, Type V (000), unprotected wood frame building, without a basement, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - MAIN BUILDING Component - 02
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 documentation review and interview, it was determined the facility failed to maintain the emergency generator monthly battery testing in one instance, affecting the entire facility.
Findings include:
1. Review of documentation on September 20, 2023, at 9:30 a.m., revealed the facility failed to perform the required monthly conductance testing of the emergency generator battery.
Interview with the Maintenance Director on September 20, 2023, at 11:30 a.m., confirmed the above listed emergency generator battery testing deficiency.
Plan of Correction:SWEC Lead Technician (Maintenance Director) purchased a battery conductance tester to have on-site for the facility emergency generator. The Lead Technician performed a conductance test on the emergency generator battery with a good result. SWEC Lead Technician contacted Smalley Electric to add the monthly battery conductance test completion to the scope of maintenance and monitoring services they provide. The wording, battery conductance monthly test added to the emergency generator form completed by Smalley Electric during their weekly on-site visit. SWEC Lead Technician will review completed emergency generator testing form monthly for accurate completion, initial and date. If the form is identified to not be completed accurately, Smalley Electric will be notified. The emergency generator testing forms will be reviewed at the Quality Assessment and Performance Improvement committee meeting for accuracy and completion.
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