Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID #17301501
Component 01
Main Building
Based on a Relicensure Survey completed on October 4, 2023, it was determined that Progressive Laser Surgical Institute, Ltd. 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 V (000), unprotected wood frame structure, which is partially sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Electrical Systems - Essential Electric Sys
Name - MAIN BUILDING 01 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 to 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 provide documentation of emergency generator fuel sample quality results, which serves the entire component.
Findings include:
1. Review of documentation on October 4, 2023, between 9:45 AM and 10:45 AM, revealed the facility failed to provide documentation verifying the quality of the emergency fuel reserve, within the previous twelve months.
Interview with the Director of Operation on October 4, 2023, at 10:45 AM, confirmed the lack of documentation.
Plan of Correction:Corrective Action:
The Center had a generator fuel test performed on 10/16/23, results of which should be received in three weeks.
Responsible Party: Administrator
Monitoring Activity:
The Administrator will review annual generator inspection reports, to ensure fuel testing has been performed. Results of annual generator testing will be brought up at the QAPI Comittee and any deviations will be reported to the Governing Body.
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