Initial Comments:
Name - CLASS C ASF Component - 01
Facility ID # 27171500
Component 01
Building 01
Based on a Relicensure Survey completed on January 6, 2021, it was determined that 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
General Requirements - Other
Name - CLASS C ASF Component - 01
General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.
Observations:
28 Pa. Code 553.3(1) GOVERNING BODY RESPONSIBILITIES
Governing body responsibilities include:
(1) Conforming to applicable Federal, State and local law. This REGULATION has not been met.
35 P.S. 448.808. Issuance of license.
(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:
(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;
Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal, State and local laws and regulations.
Findings include:
1. Observation on January 6, 2021, at 10:15 a.m., revealed the facility failed to obtain required Department of Health, Division of Safety Inspection Plan approval for a removing a wall and a corridor door at the sterile supply storage area, for the purpose of converting two existing rooms into one new larger room.
Interview at the exit conference with the Administrator, Director of Nursing and Materials Manager on January 6, 2021, at 11:20 a.m., confirmed the facility failed to obtain Department of Health plan approval prior to initiating facility modifications.
28 Pa Code 51.3. Notification (d)
Plan of Correction:Abington Surgical Center has entered into an agreement with Alliance Architecture to review the changes made at the surgical center.
Details of the agreement are detailed below:
Project Summary:
This project will encompass the design and documentation for minor modifications to two former existing storage rooms to become one larger storage room. The project encompasses design and documentation of minor modifications to approximately 100 SF within the semi-restricted area of the surgery facility. The modifications were completed prior to ALLIANCE being engaged, and as such the professional services are being provided "after-the-fact" as approval/record documentation. Because the majority of the proposed construction was undertaken prior to our involvement it is understood that it is the intent of the services to provide the proper documentation, and if identified, prepare design reparations that the project may be submitted to and approved by Pa DOH DSI for approval and subsequent inspection.
Proposed Sequence / Time line:
- Prepare proposal for limited professional services.
- January 25, 2021
- Survey current existing conditions in the proposed area of work.
- Begin End of January
- Prepare previously existing conditions, utilizing archive drawings and photographs, demolition documentation for the conditions existing prior to the construction / modification of the area.
- Early February
- Code review related to the area of modification and what is the code required work. This will include a review of the former existing conditions, current existing conditions, and if required, documenting remaining work to be done or existing conditions to be modified in order to become code compliant.
- Early February
- Prepare code compliant architectural/MPE designs and documentation of the proposed combined storage room.
- End of February
- Submittal to Pa DOH/DSI for plan review and approval
- o End of February
- Submittal to local authorities for review and approval will be the responsibility of Abington ASC or the selected contractor.
- End of March (After receiving approval from Pa DOH/DSI)
- Construction modifications to existing spaces to be compliant with applicable codes including FGI, NFPA, IBC/IEBC.
- Complete in April 2021.
This process will be submitted to the patient safety committee and to the board of directors. Additionally, the executive director will consult with architects with knowledge of PA DOH requirements prior to making any changes to the building to ensure compliance with all rules and regulations.
28 Pa. Code § 569.2 STANDARD
Fire Alarm System - Testing and Maintenance
Name - CLASS C ASF Component - 01
Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5
Observations:
Based on document review and interview, it was determined the facility failed to ensure fire alarm system devices were tested, affecting the entire facility.
Findings include:
1. Document review on January 6, 2021, at 8:15 a.m., revealed the facility could not provide documentation a two year smoke detector sensitivty test had been performed within the previous 24 months.
Interview at the exit conference with the Administrator, Director of Nursing and Materials Manager on January 6, 2021, at 11:20 a.m., confirmed the documentation was unavailable.
Plan of Correction:A two-year smoke detector sensitivity test was performed on January 11, 2021 by Johnson Controls. The report is now available at the facility. Abington Surgical Center has reviewed and amended its agreement with Johnson Controls to ensure future compliance with a smoke detector sensitivity test being performed every two years.
This deficiency will be reported to the Performance Improvement committee and safety committee and the board of directors.
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - CLASS C ASF 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 observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.
Findings include:
1. Observation on January 6, 2021, at 10:52 a.m., revealed inside the mechanical room, clearance around the sprinkler riser was obstructed by boxes.
Interview at the exit conference with the Administrator, Director of Nursing and Materials Manager on January 6, 2021, at 11:20 a.m., confirmed the sprinkler riser was obstructed by boxes.
2. Observation on January 6, 2021, at 10:53 a.m., revealed inside the mechanical room, a flow switch unit on the sprinkler riser had a loose cover.
Interview at the exit conference with the Administrator, Director of Nursing and Materials Manager on January 6, 2021, at 11:20 a.m., confirmed the switch had a loose cover.
Plan of Correction:The boxes obstructing the sprinkler riser were removed. The loose cover on the flow switch unit will be addressed and then reviewed in February 2021 when Johnson Controls will be on sight.
The Abington Surgical Center has a monthly facilities inspection check list performed by the safety officer. The safety officer or designee in his/her absence, performs this monthly inspection of the Facility. Abington Surgical Center will add an inspection of inside the mechanical room to insure there are no obstructions to the sprinkler riser and to ensure there are no loose switch covers to these monthly inspections. Any violations will be immediately addressed. The Executive Director will be notified if there are any problems. This deficiency will be communicated to the patient safety committee and the board of directors.
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 protect electrical wiring, affecting the entire facility.
Findings include:
1. Observation on January 6, 2021, between 10:20 a.m. and 10:30 a.m., revealed junction boxes with missing or unsecured covers above the suspended ceiling, at the following locations:
a. 10:20 a.m., inside the Conference Room, an unsecured junction box;
b. 10:30 a.m., inside the Pharmacy Anaesthesia Workroom, a large junction box was missing its cover.
Interview at the exit conference with the Administrator, Director of Nursing and Materials Manager on January 6, 2021, at 11:20 a.m., confirmed the unprotected electrical wiring in the above named locations.
Plan of Correction:A purchase order has been issued to a certified electrician for repairing the unsecured junction box in the ceiling of the conference room and for adding a cover to the junction box in the ceiling of the anesthesia workroom. This work is due to be complete the week of January 18, 2021.
The deficiency and repairs will be reported to and discussed in the next Patient Safety committee meeting and will be reported to the Board of Directors.
28 Pa. Code § 569.2 STANDARD
Gas and Vacuum Piped Systems - Maintenance
Name - CLASS C ASF Component - 01
Observations:
Based on document review and interview, it was determined the facility failed to maintain medical gas system components in operable condition, affecting the entire facility.
Findings include:
1. Document review on January 6, 2021, at 8:15 a.m., revealed the following deficiencies listed on the December 3, 2020 annual medical gas inspection report were not repaired:
a) Report page 3, master alarm failed gas specific demand checks and lag alarm not installed;
b) Report page 4, manifold vent lines not installed;
c) Report page 5, Vacuum discharge no turndown or screen installed, lag not connected, no flex lines on outlets.
Interview at the exit conference with the Administrator, Director of Nursing and Materials Manager on January 6, 2021, at 11:20 a.m., confirmed the deficiencies listed in the report had not been repaired.
Plan of Correction:A purchase order was issued to Beacon Medaes to address the deficiencies listed in the December 3, 2020 annual medical gas inspection report. The purchase order states in part:
Having your medical gas equipment serviced by our (Beacon Medaes) experienced, factory-trained service technicians will ensure service is properly carried out, resulting in higher operational efficiency. We only use Genuine Parts and Lubricants, which will protect your investment and guarantee high performance levels.
This Is The Quote For Doing Some Of The Deficiencies from The Annual Testing.
Includes Installing Copper Relief Piping On The Three Manifolds In The Back Manifold Rooms.
Adding Piping To Relief Outside The Building From The Manifold Room on All Three Manifolds As Per Code.
Includes Putting The Elbow and Screen On The Vacuum Exhaust Pipe Coming From The Vacuum System
Outside The Building As Per NFPA Code.
Includes Running The Wire From The Vacuum Pump Control Cabinet To The Master Alarm In The Main Office.
Includes Putting The Demands Checks On The Pressure Switches & Vacuum Switches, and Gauges On
The Main Line For Oxygen, N2O, N2 & Vacuum
"Please Note Will Need To get a HVAC Mechanic To Install The Mechanical Ventilation In The Manifold
Room As Per NFPA Code One Foot ( 12 Inches) From Floor With Mechanical Exhaust."
Lifeline System 5 H/P Reitschcle Lube Vacuum System.
Model # LTV-5D-L120-DA
Pump Model VC-150
Serial # 83343
Hilrom Med-Plus Liquid Oxygen Manifold With Six High Pressure Reserve.
Model # 6804-9040-054 - Serial # ECHAH0005
Lifeline N2O 2 X 2 High Pressure Manifold.
Model # 107011-02 - Serial # 424A493
Lifeline Nitrogen 2 X 2 High Pressure Manifold.
Model # 107014-02 - Serial # 419A386
The facilities director, under the supervision of the executive director will ensure that any deficiencies reported in the annual medical gas inspection report will corrected within 30 days of the report being issued. This deficiency and the repairs will be reported to our patient safety committee and the board of directors.
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, interview and document review, it was determined the facility failed to ensure the emergency generator was tested; failed to install a remote emergency stop switch for the emergency generator, affecting the entire facility.
Findings include:
1. Document review on January 6, 2021, at 8:15 a.m., revealed the facility could not provide documentation a three year, four hour exercise had been performed on the facility's emergency generator.
Interview at the exit conference with the Administrator, Director of Nursing and Materials Manager on January 6, 2021, at 11:20 a.m., confirmed the documentation was unavailable.
2. Observation on January 6, 2021, at 11:03 a.m., revealed there was no remote manual stop station for the emergency generator outside the room housing the prime mover or outside the housing for exterior generators.
Interview at the exit conference with the Administrator, Director of Nursing and Materials Manager on January 6, 2021, at 11:20 a.m., confirmed a remote emergency manual stop switch (E-Stop) was not installed.
Plan of Correction:Documentation of a three-year, four-hour exercise of the facilities emergency generator is now available at the facility. The test was performed on January 8, 2021 by Scotts Emergency Lighting and Power Generation Company. To ensure future compliance with the four-hour test we modified our contract with Scotts Emergency Lighting and Power Generation Company to change our two-hour load testing to a four-hour test to be performed every three years.
A purchase order has been issued to Scotts Emergency Lighting and Power Generation Company to install a remote manual stop station for the emergency generator outside the room housing the prime mover or outside the housing for exterior generators.
The purchase order ensures the follow will be installed:
1 0 SWITCH, RED, 40MM MUSHROOM-REMOTE E- SC0999
60 0 CABLE-16/2 AWG, STRANDED COPPER SC0999
4 0 PIPE-PVC, SCHEDULE 40 1/2IN X 10FT SC0999
4 0 ELBOW-90 DEGREE PVC SCHEDULE 40 PVC SC0999
1 0 MISC HARDWARE/FASTENERS SC0999
1 0 BOX, ELECTRICAL W/COVER SC0999
Service of a mechanic and mechanics helper to travel to jobsite and perform quoted service.
* Dig trench 18 inches deep from generator set to building and then 90 degrees up to box.
* Entry into building made by utilizing existing unsealed opening (boxed) and drop down wall inside where e-stop switch to be located.
* Pull and land conductors at genset controller and e-stop station.
* Test e-stop function and verify operation
These deficiencies and correction will be reported to the Patient Safety committee and Board of Directors.
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