QA Investigation Results

Pennsylvania Department of Health
ALFRED I DUPONT HOSPITAL FOR CHILDREN SURGERY CENTER BRYN MA
Building Inspection Results

ALFRED I DUPONT HOSPITAL FOR CHILDREN SURGERY CENTER BRYN MA
Building Inspection Results For:


There are  12 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - CLASS C ASF Component - 01

Facility ID# 23801501
Component 01
2nf Floor, Suite 1600

Based on a Relicensure Survey completed on August 17, 2020, it was determined Alfred I Dupont Hospital for Children Surgery Center, Bryn Mawr was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.

This is a four story, Type II (000), unprotected noncombustible construction, which is fully sprinklered.

Approved as a Class C Ambulatory Surgical Facility.



Plan of Correction:




28 Pa. Code 569.2 STANDARD
Utilities - Gas and Electric

Name - CLASS C ASF Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2

Observations:

Based on observation and interview, it was determined the facility failed to remove temporary electrical wiring from initial construction.

Findings include:

1. Observation on August 17, 2020, at 11:50 AM, revealed a length of abandoned temporary electrical wiring, located behind the vertical column within the Post Op Corridor.

Interview with the Administrator on August 17, 2020, at 11:50 AM, confirmed the temporary wiring had not been removed.






Plan of Correction:

Temporary wire was removed from behind the vertical column within the Post-op Corridor on 8/27/20. As part of the plan of correction, all ceiling tiles will be lifted and inspected for any wiring or other items inadvertently left during construction. This will be completed by 8/28/20. In order to prevent this from occurring in the future, inspection above ceiling tiles will be added to the environment of care rounding tool and will be monitored and tracked by EOC rounds done quarterly by the facilities manager. EOC rounding and monitoring will also be done immediately following any new facility construction or revisions. All data will be reported to the Environment of Care Committee which meets monthly


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 provide an emergency shut off for the generator, affecting the entire component.

Findings include:

1. Observation on August 17, 2020, at 12:30 PM, revealed the generator lacked a remote manual stop station outside the generator housing.

Interview with the Administrator on August 17, 2020, at 12:30 PM, confirmed the lack of a manual emergency shut off located outside the generator housing.





Plan of Correction:

Emergency shut off for the generator will be installed outside of the generator housing. A contractor, (Highfield Electric) was hired on 8/18/20, a proposal was sent 8/21/20 and approved, parts were ordered ( PO# 1037527) on 8/27/20 and the contractor has given a date of September 3, 2020 for installation and completion of project. Emergency shut off will be tested once installation is completed and while both the contractor and facilities manager are on site. The facilities manager will oversee the project and report back to the Environment of Care Committee.


28 Pa. Code 569.2 STANDARD
Electrical Equipment - Power Cords

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 surge suppressors, affecting the entire component.

Findings include:

1. Observation on August 17, 2020, at 11:42 AM, revealed a surge suppressor supplying power to a personal space heater within Room 207.

Interview with the Administrator on August 17, 2020, at 11:42 AM, confirmed the use of a surge suppressor to supply electricity to a personal space heater.



Plan of Correction:

Hospital approved personal space heater was plugged into a surge suppressor. Plan of correction was to remove the space heater plug from the surge suppressor immediately ( 8/17/20). The space heater, if used, will be plugged directly into a hospital grade wall receptacle. As part of the plan of correction, environment of care rounds will include inspection of all devices and equipment for compliance with use of surge suppressors. In order to prevent this from occurring in the future, this inspection will be placed on the environment of care rounding tool and will be monitored and tracked as part of EOC rounds done quarterly by the facilities manager. This information will be reported to the Environment of Care Committee. The Ambulatory Surgery Center staff will augment the quarterly rounding with monthly EOC rounding and will monitor and track for compliance. This information will be discussed and reviewed at the Ambulatory Surgery Center monthly staff meetings. Staff education was done in the moment on 8/17/20 by the facility manager and the Ambulatory Surgery Center's clinical director. Surge suppressor usage will become an agenda item for staff meetings going forward.

Updated 9/8/20 - The personal space heater was removed from the premises. No personal space heaters will be allowed in the facility from this date forward. It will still be part of the EOC checklist - making sure that no space heaters are found. Findings will be reported to the EOC committee. Education with staff has been completed as of 9/8/20