Initial Comments:
Name - MAIN BUILDING A101 Component - 01
Facility ID# 23651501
Component 01
Building 01
Based on a Relicensure Survey completed on August 10, 2022, it was determined that Capital Surgery and Laser 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 II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - MAIN BUILDING A101 Component - 01
Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to provide a remote manual stop for the emergency generator, which supplies power to the entire component.
Findings include:
1. Observation on August 10, 2022, at 11:15 AM, revealed the generator remote manual stop station was installed within the generator cabinet. NFPA 110 - 3.5.5.6
Interview with the Administrator on August 10, 2022, at 11:15 AM, confirmed the switch was installed in the same container as the generator.
Plan of Correction:Corrective action to be taken:
Cleveland Brothers Equipment Company will complete the following work to generator. Pull wires from generator into the transfer switch to add emergency stop button. Mount an emergency stop button with clear tamper proof cover on the side of the transfer switch. Make connections for the emergency stop and test for proper operation.
Description of action taken:
Cleveland Brothers Company was made aware of surveyor's observations on 8/10/22. Dustin Hoffman, Account Manager arrived on site on 8/11/22 to observe generator and review surveyor's observations. Dustin Hoffman arrived on site on 8/15/22 to assess current generator and wiring. A quotation was received on 8/18/22 for the work required to correct deficiency based on surveyor's observations. A signed proposal was sent to Cleveland Brothers on 8/18/22. Cleveland Brothers is scheduled to complete work on 9/1/22.
All operations will be tested to insure proper operation.
Monitoring and Education:
Generator record compliance will be maintained on weekly and monthly basis. All records are maintained by Administrator and will be available upon request.
The administrator informed staff of the surveyor's observations and provided education regarding use of emergency stop button to staff on 8/26/22. Those not present for the education on 8/26/22 will be provided education and acknowledge understanding of the changes on their next scheduled day of work. All staff members will be educated on use of emergency stop for generator again at time of completion and also on annual basis.
Once 100% compliance of staff education is achieved, audits will be conducted on a annual basic to ensure understanding.
The administrator will provide findings from the survey, corrective actions and results to the Governing Board, Patient Safety Committee and QAPI Committee.
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - MAIN BUILDING A101 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 the emergency generator, which serves the entire component.
Findings include:
1. Observation on August 10, 2022, at 11:00 AM revealed the room housing the emergency transfer switch lacked battery-powered emergency lighting.
Interview with the Administrator on August 10, 2022, at 11:00 AM confirmed the room lacked battery lighting.
Plan of Correction:Corrective action to be taken:
Cleveland Brothers Equipment Company will complete the following work in mechanical room housing the emergency transfer switch. Correct the emergency lighting in mechanical room by replacing the light and motion sensor.
Make connections for the emergency stop as necessary and test for proper operation.
Description of action:
Cleveland Brothers Company was made aware of surveyor's observations on 8/10/22. Dustin Hoffman, Account Manager arrived on site on 8/11/22 to review surveyor's observations and centers operations. Dustin Hoffman and an Electrician arrived on site on 8/15/22 to assess current generator and wiring. A quotation was received on 8/18/22 for the work required to correct deficiency. A signed proposal was sent to Cleveland Brothers on 8/18/22. Cleveland Brothers is scheduled to complete work on 9/1/22.
Monitoring and Education:
Generator record compliance will be maintained. All emergency lighting will be tested to ensure compliance. All records are maintained by Administrator and will be available upon request.
The administrator will provide findings from the survey, corrective actions and results to the Governing Board, Patient Safety Committee and QAPI Committee.
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