Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID# 27171500
Component 01
Building 01
Based on a Relicensure Survey completed on December 12, 2022, it was determined Abington Surgical Center, LP 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 non-combustible construction, which is partially sprinklered.
Plan of Correction:
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 document review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.
Findings include:
1. Document review on December 12, 2022, at 8:30 a.m., revealed the facility could not provide documentation monthly electrolyte specific gravity or conductance testing was performed.
Exit interview with the Administrator on December 12, 2022, at 10:00 a.m., confirmed the lack of testing.
Plan of Correction:Abington Surgical Center does weekly electrolyte specific gravity testing on the emergency generator battery. These weekly test results are recorded in a log book kept by the facilities manager. The entry in the log indicates if the test was passed or failed, but numeric results are not recorded.
The Surgical Center will systematically change our testing procedure to a monthly conductance testing performed by the facilities manager.
The test will include:
- Date/Time of test
- Voltage
- Pass/Fail, Red/Green or Good/Bad (depending on testing device)
- Cold Cranking Amps (if provided on the testing device)
- Outdoor temperature (for batteries located outdoors only)
The Center purchased a new QPKING BT660 Battery Conductance Tester to perform the battery testing.
The Center will continue to follow all battery and generator manufacture's recommendations for battery maintenance and replacement.
The Center's policy on battery testing will be updated to reflect the above changes.
Once the new testing procedure is in place starting in January 2023, the test results will be audited by the Executive Director for a 3-month period.
This deficiency and plan of correction will be reported to the patient safety committee and to the Board of Directors
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