Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on January 4, 2024, at Mountain Laurel Surgery Center, LLC., it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - MAIN Component - 01
Facility ID# 20571501
Component 01
Main Building
Based on a Recertification Survey completed on January 4, 2023, it was determined that Mountain Laurel Surgery Center, LLC., 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, with a basement, that is nonsprinklered.
Plan of Correction:
NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag
Name - MAIN Component - 01
Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to maintain cylinder storage in one location, affecting one of two floors.
Findings include:
1. Observation on January 4, 2023, at 10:32 a.m., revealed two unsecured H-style oxygen cylinders, located within the medical gas manifold enclosure.
Interview with the Facillity Administrator at 10:33 a.m., on January 4, 2023, confirmed the oxygen cylinder storage deficiency.
Plan of Correction:January 5, 2024
Maintenance supervisor David Campeau and contracted Oxygen Supplier was contacted. Discussion occurred regarding the observation of two unsecured oxygen cylinders located in the medical gas manifold enclosure.
January 9, 2024
All maintenance, housekeeping and surgical techs attended a brief in-service on proper handling and storage of oxygen cylinders located in medical gas manifold enclosure.
January 15, 2024
Quality improvement measure will be added to the daily Oxygen Log. This audit tool will be completed daily for 4 weeks, then weekly for 5 months. The QI tool will be reviewed monthly by the committee for six months in which at that time the committee will re-evaluate the continued need for the audit. Deficiency in this practice will result in disciplinary action of the responsible employee.
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