Initial Comments:
Name - MAIN LINE VASCULAR INSTITUTE Component - 01
Facility ID# 24251501
Component 01
Based on a Relicensure Survey completed on July 19, 2022, it was determined that Main Line Vascular Institute LLC, was not in compliance with the following requirements of the Life Safety Code for an existing Ambulatory health care occupancy.
This is a three-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN LINE VASCULAR INSTITUTE 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 document review and interview, it was determined the facility failed to maintain, inspect, and test fire sprinkler systems, in one of four annual quarters.
Findings include:
1. Document review on July 19, 2022, at 10:37 a.m., revealed the facility lacked documentation to indicate a quarterly test of the fire sprinkler system was performed during the first quarter.
Exit Interview with the Director of Nursing on July 19, 2022, at 11:45 a.m., confirmed the above fire sprinkler inspection was not on-site during the time of the survey.
Plan of Correction:The Director of Nursing will be responsible for ensuring that the Sprinkler System is inspected quarterly as per State regulations. This will be audited Quarterly and documented on the Monthly Environment of Care checklist. Audits will be reported to the Quality Assurance Committee, which reports to the Governing Body. Any deficiencies will be addressed by the governing body. All staff will be in-serviced on the required Sprinkler inspections, by 8/31/2022. In-service records will be reported to the Patient Safety Committee which reports to the Quality Assurance Committee. Any Deficiencies will be addressed by the Governing Body.
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - MAIN LINE VASCULAR INSTITUTE 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 document review and interview, it was determined the facility failed to maintain essential electric system maintenance and testing, for one of one emergency generator.
Findings include:
1. Document review on July 19, 2022, at 10:55 a.m., revealed the facility lacked documentation to indicate an annual fuel analysis report was conducted for the emergency generator.
Exit Interview with the Director of Nursing on July 19, 2022, at 11:45 a.m., confirmed the annual fuel analysis report was not available at the time of the survey.
Plan of Correction:The Director of Nursing will schedule the certified contractor to complete the annual fuel analysis by 8/31/2022. The contractor will provide a report and paperwork showing that the analysis was completed. This paperwork will be submitted to the Quality Assurance Committee for review. The Director of Nursing will audit quarterly that the annual fuel analysis report is completed and filed at the facility. This will be documented on the Environment of Care Checklist. All staff will be in-serviced on the annual fuel analysis requirement by 8/31/2022. In-service records will be reported to the Quality Assurance Committee which reports to the Governing Body. Any deficiencies will be addressed by the governing body.
|