Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 21331501
Component 01
Main Building
Based on a Relicensure Survey completed on September 23, 2020, it was determined that Cornerstone Ambulatory Surgery Center, 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 V (000), unprotected wood frame construction, which is fully sprinklered.
Approved as a Class C Ambulatory Surgical Facility.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Exit Signage
Name - CLASS C ASF Component - 01
Exit Signage
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
20.2.10, 21.2.10, 7.10
Observations:
Based on document review and interview, it was determined the facility failed to maintain exit signs in operable condition, affecting the entire facility.
Findings include:
1. Document review on September 23, 2020, at 8:30 a.m., revealed the monthly exit sign inspection report dated August 5, 2020 noted 13 battery backup exit sign batteries needed to be replaced. At the time of the survey, the batteries had not been replaced.
Interview at the exit conference with the Administrator on September 23, 2020, at 12:50 p.m., confirmed the exit sign lighting was inoperable.
Plan of Correction:Fidelity Alarm Company advised the CASC on 10/8/2020 that they made an error an only 3 of the 13 batteries needed to be replaced in the exit signs. The 3 batteries were replaced by Fidelity Alarm company on 9/23/2020. Documentation of completion are on file at the CASC. The DON will continue to do weekly checks on Exit signs in accordance with the standard- Exit Signage Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 20.2.10, 21.2.10, 7.10. Fidelity will continue to do quarterly checks to ensure compliance with standard- Exit Signage Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 20.2.10, 21.2.10, 7.10 7.10. We will discuss this at our next staff meeting and make sure that this testing is complete and noted on all documentation.
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - CLASS C ASF 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 observation and interview, it was determined the facility failed to maintain automatic sprinkler system components in operable condition, affecting one of two smoke zones within the facility.
Findings include:
1. Observation on September 23, 2020, at 11:30 a.m., revealed a sprinkler escutcheon was dislodged from the ceiling, above the double doors, from the recovery area to the sterile corridor.
Interview at the exit conference with the Administrator on September 23, 2020, at 12:50 p.m., confirmed the sprinkler escutcheon dislodged from the ceiling.
Plan of Correction:G.C. Inc. Contractor repaired the sprinkler escutcheon was dislodged by adjusting the sprinkler head to be flushed with ceiling. The contractor made the repair to sprinkler escutcheon dislodged sprinkler head above the double doors, from the recovery area to the sterile corridor. G.C Inc. Contractor on 9/25/2020 upon his inspection. He repaired the sprinkler head and inspected all sprinklers within the facility.
We will continue to inspect the sprinkler heads for any gaps during our monthly walk through on our Preventive Maintenance Checklist. These issues will be discussed at our next staff meeting. The DON will be responsible for monitoring ongoing compliance.
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - CLASS C ASF 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 observation and interview, it was determined the facility failed to maintain access to emergency generator system components, affecting the entire facility.
Findings include:
1. Observation on September 23, 2020, at 11:45 a.m., revealed inside the mechanical room, the emergency generator transfer switch panel was obstructed by boxes stored in front of it.
Interview at the exit conference with the Administrator on September 23, 2020, at 12:50 p.m., confirmed access to the emergency generator transfer switch panel was obstructed.
Plan of Correction:In compliance with NFPA 111 the boxes were removed on 9/23/2020 from
underneath the emergency generator transfer switch panel in the mechanical room. The DON will monitor during weekly maintenance checklist to ensure there is no obstruction under any electrical panel in the facility and will be discussed at our staff meeting.
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