Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID # 25101501
Component 01
Based on a Relicensure Survey completed on May 4, 2023, it was determined that King Of Prussia Surgery Center, LLC, was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.
This is a one story, Type II (000), unprotected non-combustible construction, which is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Means of Egress - General
Name - CLASS C ASF Component - 01
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1
Observations:
Based on document review and interview, it was determined the facility failed to properly document the required annual fire door inspection, for one required inspection.
Findings include:
1. Document review on May 4, 2023, at 9:30 am, revealed the facility could not produce documentation showing that an annual fire door inspection was performed as required.
Exit Interview with the Administrator and Director of Nursing on May 4, 2023, at 11:15 am, confirmed the missing documentation.
Plan of Correction:On 5/16/23 Lincoln Harris, CSG was contracted to perform the annual fire door inspection (please see attachment of completed assessment). No issues were found. This requirement has been added to our EOC Safety Checklist. The EOC safety checklist is where we track completion of all EOC requirements. Results are maintained on file in a binder onsite for review. This file is maintained by the business manager with oversight of completion by administrator.
NFPA 101 STANDARD
Emergency Lighting
Name - CLASS C ASF Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
Observations:
Based on document review, and interview, it was determined the facility failed to maintain its emergency lighting, affecting four operating rooms.
Findings include:
1. Document review on May 4, 2023, at 9:30 am, revealed the facility lacked documentation of the following required tests of the battery back-up lighting in the OR ' s:
a. monthly 30-second test.
b. annual 90-minute test.
Exit Interview with the Administrator and Director of Nursing on May 4, 2023, at 11:15 am, confirmed the missing documentation.
Plan of Correction:On 5/8/23 vendor MFS Systems was contracted to respond to perform the 90 minute annual test (see documentation) for battery backup lighting in the ORs. The system passed. This requirement was added to our EOC safety checklist. The safety checklist is the facilities method for tracking requirements for facility and environment. THe backup documentation of all tests/inspections is kept in a binder onsite for review. The 30 second monthly test has also been added to the checklist and is currently up to date. The checklist and binder are maintained by the business manager with oversight from the administrator.
NFPA 101 STANDARD
HVAC
Name - CLASS C ASF Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Based on document review and interview, it was determined the facility failed to maintain inspection of Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting the entire facility.
Findings include:
Document review on May 4, 2023, at 9:30 am, revealed the facility lacked documentation showing that required testing/inspection of the fire/smoke dampers was performed 1-year after installation.
Interview at the exit conference with the Administrator and Director of Nursing on May 4, 2023, at 11:15 am, confirmed fire/smoke damper inspection documentation was not on-site during the time of the survey.
Plan of Correction:on 5/8/23 MFS was contracted to inspect the damper. The damper passed inspection and documentation is available. This inspection will be repeated in 4 years. It has been added to our Safety and Environment checklist which is maintained by the business manager with oversight by the administrator. THe backup documentation for inspections/tests is kept in a binder onsite for review readily.
NFPA 101 STANDARD
Electrical Systems - Maintenance and Testing
Name - CLASS C ASF Component - 01
Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
Observations:
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested at patient bed locations within the facility.
Findings include:
1. Document review on May 4, 2023, at 9:30 am, revealed electrical receptacles at patient bed locations, and in locations where deep sedation or general anesthesia is administered, were not tested as required for non-hospital grade receptacles at intervals not exceeding 12 months. Receptacle testing should include the following:
a. visual inspection of physical integrity.
b. correct polarity of the hot and neutral connections.
c. retention force of the grounding blade (except locking-type receptacles) shall not be less than 4 oz.
*The facility failed to conduct the (c.) retention portion of receptacle testing.
Interview at the exit conference with the Administrator and Director of Nursing on May 4, 2023, at 11:15 am, confirmed testing of electrical receptacles was incomplete.
Plan of Correction:on 5/19/23 vendor Malco was contracted to perform the retention portion of the receptacle testing. The receptacles were certified by the vendor. Documentation is available validation same. This has been added to our safety environment checklist which is maintained by the business manager with oversight from the administrator. THis will be performed every 12 months going forward. Backup documentation of all testings/inspections is maintained in a binder onsite for review upon request.
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