Initial Comments:
Name - ALLIED SERVICES HOSPICE Component - 01
Facility ID# 17731601
Component 01
Main Building
Based on a Recertification/Relicensure Survey completed on July 10, 2024, it was determined that Allied Services Hospice was not in compliance with the following requirements of the Life Safety Code for a new hospice health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 418.110 (d).
This is a one story, Type V (111), protected, wood frame building, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - ALLIED SERVICES HOSPICE 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 4 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, readily identifiable, and separate from normal power circuits. 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 observation and interview, it was determined the facility failed to maintain the emergency generator which serves the entire center.
Findings include:
1. Observation on July 10, 2024, at 10:45 a.m., revealed the facility's emergency generator lacked a remote emergency stop station, located externally from the generator.
Exit interview with the Facilities Manager and Assistant VP of Facilities on July 10, 2024, at 11:00 a.m., confirmed the lack of the generator emergency stop station.
Plan of Correction:A remote emergency stop station for the emergency generator will be installed external the generator. The remote generator stop station will be installed as per NFPA 110, 2010 edition and NFPA 70, 2011 edition. The remote emergency stop station will be added to the facility services inventory; it will be inspected and tested as required. This process will be the responsibility of the Assistant Vice President, Facility Services.
Initial Comments:
Name - MEADE STREET HOSPICE CENTER Component - 10
Facility ID# 17731601
Component 10
Meade Street Facility
Based on a Recertification/Relicensure Survey completed on July 10, 2024, at Allied Services Hospice, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for a new hospice health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 418.110 (d).
This is a one story, Type II (000), unprotected, noncombustible building, with a partial basement, that is fully sprinklered.
Plan of Correction:
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