Initial Comments:
Name - PEDIATRIC EXTENDED CARE CENTER Component - 01
Facility ID# 18624001
Component 01
Main Building
Based on a Relicensure Survey completed on May 10, 2023, it was determined that Harleysville Pediatric Home Care And Extended Services was not in compliance with the following requirements of the Life Safety Code for an existing Pediatric Extended Care health care occupancy.
This is a two-story, Type III (211), protected ordinary structure, with a basement, which is not sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Electrical Systems - Other
Name - PEDIATRIC EXTENDED CARE CENTER Component - 01
Electrical Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Observations:
Based on observation and interview, it was determined the facility failed to maintain protection of electrical wiring, affecting one of two floors.
Findings include:
1. Observation on May 10, 2023, at 9:50 am, revealed in ground floor utility room, electrical panel #1 was missing a circuit breaker protective blank.
Exit Interview with the Program Director on May 10, 2023, at 10:15 am, confirmed the missing blank.
~Refer to 2011 edition of NFPA 70-314.28.
Plan of Correction:The missing circuit breaker blank was added on 5/16/23. Maintenance was re-educated on electrical safety on 5/16/23. I started a monthly checklist for myself to be on the lookout for electrical safety issues which I will begin June 2023.
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - PEDIATRIC EXTENDED CARE CENTER 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. Document review on May 10, 2023, at 9:10 am, revealed the facility could not produce documentation showing a 3-year 4-hour exercise of the generator had been performed.
Exit Interview with the Program Director on May 10, 2023, at 10:15 am, confirmed the missing documentation.
Plan of Correction:I informed maintenance 5/16/23 that a 4 hour under load test is to be performed on the generator once every 3 years. This will be completed by June 9th 2023. A checklist was generated which shows date of completion, start time, end time, what was running to determine load and issues that occurred. I will track the completion of this test this year and future years.
28 Pa. Code § 569.2 STANDARD
Electrical Equipment - Power Cords
Name - PEDIATRIC EXTENDED CARE CENTER Component - 01
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of two floors.
Findings include:
1. Observation on May 10, 2023, at 9:35 am, revealed in ground floor med area, a 3-plug outlet multiplier was in use by the sink.
Exit Interview with the Program Director on May 10, 2023, at 10:15 am, confirmed the unauthorized electrical device.
Plan of Correction:The staff in the PPECC and IT were re-educated on electrical safety on 5/10/23. They were told no multipliers or extension cords are to be used in the patient care vicinity. We added a check to our monthly walkaround to look for extension cords and multipliers. This will be completed on a monthly basis beginning June 2023.
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