Initial Comments:Based on an Emergency Preparedness Survey completed on June 21, 2023, at New Britain Surgery Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - CLASS C ASF Component - 01Facility ID 23001501Component 01Main Building
Based on a Recertification/Relicensure Survey completed on June 21, 2023, it was determined that New Britain Surgery Center 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 II (000), unprotected noncombustible structure, which is fully sprinklered.
Approved as a Class C Ambulatory Surgical Facility (ASF).
Plan of Correction:
NFPA 101 STANDARD
Electrical Equipment - Power Cords and Extens
Name - CLASS C ASF 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 monitor the use of receptacle multipliers, affecting one of two smoke compartments within the component.
Findings include:
1. Observation on June 21, 2023, at 12:35 PM, revealed a three-to-one receptacle multiplier supplying electrical power to a copy machine in the Operations Manager's Office.
Interview with the Business Manager on June 21, 2023, at 12:35 PM, confirmed the use of a receptacle multiplier.
Plan of Correction:The three-to-one receptacle multiplier in the Operation's Manager's office has been replaced by a power strip on 6/23/2023.
The use of receptacle multipliers will not be used in the facility, this will be monitored by the Administrator.
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