QA Investigation Results

Pennsylvania Department of Health
CENTER FOR THE SURGICAL ARTS, LLC
Building Inspection Results

CENTER FOR THE SURGICAL ARTS, LLC
Building Inspection Results For:


There are  26 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Name - MAIN Component - 01
Facility ID# 18431501
Component 01
Main building

Based on a Relicensure Survey completed on December 07, 2022, it was determined that the Center for the Surgical Arts LLC, 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 II (000), unprotected noncombustible building, without a basement, that is not sprinklered.



Plan of Correction:




28 Pa. Code 569.2 STANDARD
Fire Alarm System - Installation

Name - MAIN Component - 01
Fire Alarm - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
20.3.4.2.1, 21.3.4.1, 9.6

Observations:

Based on observation and interview, it was determined the facility failed to install required fire alarm system components in one instance, affecting the entire facility.

Findings include:

1. Observation on December 7, 2022, at 10:40 a.m., revealed there was no automatic smoke or heat detector in the room housing the main fire alarm control panel.

Interview with the Facility Administrator and Facility Staff on December at 7, 2022, at 12:30 p.m., confirmed there was not a smoke detector at the main fire alarm panel.





Plan of Correction:

Contacted CSA security and fire alarm company, Secure-Tec, at (814) 696-4404 on 12/19/2022. They have us on record for the installation of a smoke detector at the main fire alarm panel. Availability for installation was not given due to the holidays. They will contact us when availability is clear and an appointment can be scheduled. Follow-up phone call scheduled on 1/4/2022 at 11 AM to check on availability if company does not contact CSA before.


28 Pa. Code 569.2 STANDARD
Fire Alarm System - Testing and Maintenance

Name - MAIN 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 documentation review and interview, it was determined the facility failed to perform the required annual and semi-annual inspection of the automatic fire alarm system, affecting the entire facility.

Findings Include:

1. Review of documentation on December 7, 2022, at 9:30 a.m., revealed the following automatic fire alarm system deficiencies:

a) the facility lacked documentation for a annual inspection of the automatic fire alarm system, the most recent inspection was performed in November of 2021;
b) the facility lacked documentation for a semi-annual visual inspection of the automatic fire alarm system, performed within the twelve months;
c) the facility lacked documentation for biennial smoke detector sensitivity testing.

Interview with the Facility Administrator and Facility Staff on December 7, 2022, at 12:30 p.m., confirmed the above listed documentation was not available at the time of the survey.






Plan of Correction:

a) Contacted CSA security and fire alarm company, Secure-Tec, at (814) 696-4404 on 12/19/2022. They have us on record to perform our annual inspection of the automatic fire alarm systems. Availability for inspection was not given due to the holidays. They will contact us when availability is clear and an appointment can be scheduled. Follow-up phone call scheduled on 1/4/2022 at 11 AM to check on availability if company does not contact CSA before.
b) Administrator and DON formulated a log sheet to be used for the semi-annual visual inspection of the automatic fire alarm system on 12/16/2022. This was discussed on 12/16/2022 as a responsibility for the facility manager. Facility Manager has been informed of this new log sheet and will now ensure a semi-annual visual inspection occurs within the twelve months of the annual inspection and will use the log sheet for record keeping. First Semi-annual will be scheduled 6 months after annual inspection.
c) Contacted CSA security and fire alarm company, Secure-Tec, at (814) 696-4404 on 12/19/2022. They have us on record to perform our annual inspection of the smoke detector sensitivity testing. Availability for inspection was not given due to the holidays. They will contact us when availability is clear and an appointment can be scheduled. Follow-up phone call scheduled on 1/4/2022 at 11 AM to check on availability if company does not contact CSA before.



28 Pa. Code 569.2 STANDARD
Sprinkler System - Maintenance and Testing

Name - MAIN Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system maintenance and testing in three instances, affecting the entire facility.

Findings include:

1. Review of documentation on December 7, 2022, at 9:40 a.m., revealed the following automatic sprinkler system deficiencies:

a) the facility lacked documentation for a annual inspection of the automatic sprinkler system;
b) the facility lacked documentation for three quarterly inspection of the automatic sprinkler system;
c) the facility lacked documentation for a five year inspection of the automatic sprinkler system;

Interview with the facility Administrator and Facility Staff on December 7, 2022, at 12:30 p.m., confirmed the above listed documentation was not available at the time of the survey.






Plan of Correction:

a) Liberty Fire was contacted on 12/19/2022 to schedule an annual inspection of the automatic sprinkler system. Inspection scheduled for 1/9/2023 at 8:00 AM. This was discussed with the facility manager to ensure we have an annual inspection filed in the preventative maintenance binder. Facility manager will schedule annual inspection of the sprinklers around the same time as alarm system inspections to ensure they are done annually.
b) Liberty Fire was contacted on 12/19/2022 to schedule a quarterly inspection of the automatic sprinkler system. This was discussed with the facility manager to ensure we have a quarterly inspection of the automatic sprinkler system filed in the preventative maintenance binder. Quarterly Inspections by Liberty Fire scheduled for 4/6/2023, 7/6/2023, and 10/6/2023 at 8:00 AM.
c) Liberty Fire was contacted on 12/19/2022 to schedule a 5-year inspection of the automatic sprinkler system. 5-year inspection will occur on the date of the annual inspection on 1/9/2023 at 8 AM. This was discussed with the facility manager to ensure we have a 5-year inspection of the automatic sprinkler system filed in the preventative maintenance binder. Facility manager will also be responsible for scheduling the next 5-year inspection on 1/9/2027.



28 Pa. Code 569.2 STANDARD
Portable Fire Extinguishers

Name - MAIN Component - 01
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10

Observations:
Based on documentation review and interview, it was determined the facility failed to maintain portable fire extinguishers inspections in two instances, affecting the entire facility. in accordance with NFPA 10, 7.1.2.1.

Findings include:

1. Review of documentation on December 7, 2022, at 9:50 a.m. revelaed the following annual fire extinguisher inspection report deficiencies:

a) the annual fire extinguisher inspection report, lacked a signature of the individual who performed the inspection;
b) the facility lacked documentation indicating that the individual who conducted the annual fire extinguisher inspection was certified.

Interview with the Facility Administrator and Facility Staff on December 7, 2022, at 12:30 p.m., confirmed the above listed portable fire extinguisher documentation was not available at the time of the survey.








Plan of Correction:

a) Annual fire extinguisher report dated 1/11/2022 completed by Cory Milburn from Liberty Fire. Requested a copy signed by Cory on 12/22/2022. Signed copy will be placed on file in the preventative maintenance binder.
b) Liberty Fire was contacted on 12/19/2022 to request a copy of documentation showing the individual who conducted the annual fire extinguisher inspection was certified. Copy of certificate for Cory Milburn received on 12/19/2022. It is now on file in the preventative maintenance binder with the annual fire extinguisher report for 2022.



28 Pa. Code 569.2 STANDARD
HVAC

Name - MAIN Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2

Observations:

Based on documentation review and interview, it was determined the facility failed to ensure fire dampers were inspected within the required four-year period, affecting the entire facility.

Findings include:

1. Review of documentation on December 7, 2022, at 9:20 a.m., revealed the facility lacked documentation to indicate that fire dampers were tested inspected every four years in accordance with NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives.

Interview with the Facility Administrator and Facility Staff on December 7, 2022, at 12:30 p.m., confirmed the fire damper inspection documentation was not available at the time of the survey.







Plan of Correction:

a) Liberty Fire was contacted on 12/19/2022 to schedule a 4-year inspection of fire dampers system. 4-year fire damper inspection will occur on 1/9/2023 at 8 AM. This was discussed with the facility manager to ensure we have a 4-year inspection of the fire dampers filed in the preventative maintenance binder. Facility manager will also be responsible for scheduling the next 4-year inspection around 1/9/2027.


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

Name - MAIN 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 documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.

Findings include:

1. Review of documentation on December 7, 2022, at 9:50 a.m., revealed the facility lacked documentation for the following required emergency generator maintenance and testing:

a) weekly battery voltage test;
b) monthly conductance testing.

Interview with the Facility Administrator and Facility Staff on December 7, 2022, at 12:30 p.m., confirmed the above listed documentation was not available at the time of the survey.




Plan of Correction:

a) Administrator and Facility manager discussed a plan for weekly battery voltage testing. Facility manager will use the battery voltage log sheet each week to record the test. The log sheet will be stored in the telecommunications room, next to the generator panel. This new process will be in place by 1/30/2023.
b) Monthly conductance testing was discussed with the Facility manager. Facility manager will now make conductance testing part of his monthly work plan. Emergency Generator Conductance tester ordered on 12/16/2022 by Facility manager. Conductance testing log sheet created and will be used by the Facility manager every month and kept on file in the preventative maintenance binder. First conductance testing to be performed by the Facility administrator on 1/19/2023.