Initial Comments:
Name - CLASS B Component - 01
Facility ID# 50441501
Component 01
Mandell Pavilion
Based on a Relicensure Survey completed on July 11, 2023, it was determined that Temple University Hospital Northeastern Campus Endoscopy Center 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 (222), fire resistive construction, with a basement, which is fully sprinklered.
Approved as a Class B Ambulatory Surgical Facility.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - CLASS B 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 one sprinkler system.
Findings include:
1. Observation on July 11, 2023, at 9:30 am, revealed the basement maintenance shop sprinkler riser room lacked a sprinkler wrench.
Exit Interview with the Director of Facilities on July 11, 2023, at 9:50 am, confirmed the missing sprinkler wrench.
Plan of Correction:The Temple University Hospital Inc. Vice President of Facilities has ultimate responsibility for the implementation and monitoring of the action plan.
The facility Building Manager investigated the deficiency and found the basement level wet sprinkler system room was lacking the spare sprinkler wrench. On the day of the survey, July 11, 2023, while the surveyor was on-site, the facility Building Manager placed a sprinkler wrench in the missing location. This was verified by the Temple University Hospital Inc. (TUH) Director of Engineering. The facility Building Manager will add the presence of the wrench to the monthly building compliance checklist to verify the sprinkler wrench remains in the designated box. Verification of the presence of the wrench will also be added to the preventative maintenance matrix for the TUH Northeastern Campus- the Endoscopy Center. Any issues of non-compliance identified will be immediately resolved. The reporting of the verification results will be presented by the Director of Engineering at the TUH Northeastern Campus- the Endoscopy Center Performance Improvement meeting August 23, 2023, and then quarterly thereafter. The TUH Director of Engineering contacted the facility Building Manager to request staff re-education on the storage requirements for the sprinkler wrench. The staff education was completed on August 9, 2023.All education sign off sheets will be maintained and available upon request for review by the surveyor.
Weekly audits of the presence of the sprinkler wrench will be conducted by the Director of Engineering July 11 to August 1, 2023. Anticipated compliance is 100%
Fall outs will be corrected immediately with the placement of a new sprinkler wrench, if identified. The Director of Engineering will be notified of any instances of non-compliance.
Once 100% compliance is achieved with four weeks of weekly audits, auditing will decrease to monthly and then with continued compliance quarterly.
The audit results will be presented by the Director of Engineering at the TUH Northeastern Campus- the Endoscopy Center Performance Improvement meeting August 23, 2023.
The Vice President of Facilities or designee will report the audit results at the TUH Inc. Environment of Care meeting in September 2023.
Sustainability is identified through the results of monitoring or auditing for the below data elements. When the results do not meet the benchmark, additional actions are implemented using the plan-do-study-act (PDSA) performance improvement process. Results are re-monitored or re-audited. Remediation with individuals is conducted when an issue is identified.
The Executive Sponsor will make a recommendation as to Monitoring and Sustainability at the end of the Action Plan October 31,2023. This recommendation will be made to the TUH Inc. Environment of Care (EOC) Committee from the TUH Northeastern Campus- the Endoscopy Center Performance Improvement Committee. The decision of the TUH Inc. EOC Committee will be communicated to the committees and the individual action plan owners.
All education, sign-off sheets, audit results, Committee and Board minutes, and other pertinent documents are maintained and available upon request for review by the surveyors.
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - CLASS B 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 documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting one generator.
Findings include:
1. Document review on July 11, 2023, at 8:30 am, revealed annual fuel quality test results for the emergency generator diesel fuel were not available for review at time of survey.
Exit Interview with the Director of Facilities on July 11, 2023, at 9:50 am, confirmed the missing documentation.
Plan of Correction:The Temple University Hospital Inc. Vice President of Facilities has ultimate responsibility for the implementation and monitoring of the action plan.
The Temple University Hospital Inc. (TUH) Director of Engineering met with the facility Building Manager to discuss the missing annual fuel quality test report for the emergency generator diesel fuel. The annual fuel quality test was completed on June 26, 2023 however the final report was not received prior to the annual Pennsylvania Department of Health Life Safety inspection for the TUH Northeastern Campus- the Endoscopy Center on July 11, 2023. The annual fuel quality test report for the emergency generator diesel fuel was received on July 31, 2023 and verified by the TUH Director of Engineering.
The TUH Director of Engineering met with the facility Building Manager on July 11, 2023, to review all maintenance and testing inspections and receipt of final report dates to ensure reports are received in a timely manner. The building compliance checklist will be amended to include the timeline for receiving and reviewing reports.
A review of the checklist including report receipt dates will occur monthly by the Director of Engineering and/or his designee. Any noncompliance will be addressed immediately with the facility Building Manager. The results of the review will be presented by the Director of Engineering at the TUH Northeastern Campus- the Endoscopy Center Performance Improvement meeting August 23, 2023, and then quarterly thereafter.
Sustainability is identified through the results of monitoring or auditing for the below data elements. When the results do not meet the benchmark, additional actions are implemented using the plan-do-study-act (PDSA) performance improvement process. Results are re-monitored or re-audited. Remediation with individuals is conducted when an issue is identified.
The Executive Sponsor will make a recommendation as to Monitoring and Sustainability at the end of the Action Plan October 31,2023. This recommendation will be made to the TUH Inc. Environment of Care (EOC) Committee from the TUH Northeastern Campus- the Endoscopy Center Performance Improvement Committee. The decision of the TUH Inc. EOC Committee will be communicated to the committees and the individual action plan owners.
All education, sign-off sheets, audit results, Committee and Board minutes, and other pertinent documents are maintained and available upon request for review by the surveyors.
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