Initial Comments:Based on an Emergency Preparedness Survey completed on September 22, 2022, at Bucks County Surgical Suites, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.
Plan of Correction:
Initial Comments:
Name - CLASS C - FIRST FLOOR TENANT SPACE Component - 01Facility ID# 50511501
Component 01
Based on a Recertification/Relicensure Survey completed on September 22, 2022, it was determined that Bucks County Surgical Suites was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 416.44(b).
Plan of Correction:
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - CLASS C - FIRST FLOOR TENANT SPACE 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 observation, document review, and interview, it was determined that the facility failed to maintain the fire alarm system for one of one fire alarm systems.
Findings include:
1. Document review and interview on September 22, 2022, at 8:30 a.m., revealed the following fire alarm panel deficiencies:
a. 8:30 a.m. The facility had over 200 troubles on their fire alarm panel at the time of the survey;
b. 8:33 a.m. The facility failed to provide documentation for the sensitivity inspection at the time of the survey.
Interview with the maintenance director on September 22, 2022, at 8:33 a.m., confirmed the fire alarm deficiencies listed above.
Plan of Correction:Note: The office building in which Bucks County Surgical Suites operates has been under construction on the 2nd and 3rd floors. The alarm system on the first floor is a different manufacturer and due to proprietary rights, the 1st floor system cannot be integrated into the system servicing the 2nd and 3rd floors.
POC: The 1st floor is scheduled to be rewired with all new devices and hardware on Wednesday, October 19, 2022. With the install, there will be one system for the entire office building, and the system will be operated and maintained without proprietary restrictions.
a. The system and alarms have been reviewed by the Fire Marshals office, and they have confirmed that the system operates properly as is. The trouble alarms are due to the multiple fire systems being connected. These trouble alarms will be cleared with the installation of the new system on October 19, 2022.
b. According to the fire system contractor, the current detectors do not allow for sensitivity testing and reports. This will be corrected with the installation of the new system on October, 19, 2022. The sensitivity testing and reports are included in the contract, and they will be performed every 2 years as required.
Follow Up: The administrator works directly with the landlord to ensure the required testing is performed according to NFPA standards, and reported back to the Safety Committee and Medical Executive Committee during quarterly reviews. Any discrepancies with the testing are reported back to assist the committee in formulating a corrective action.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - CLASS C - FIRST FLOOR TENANT SPACE 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, document review, and interview, it was determined that the facility failed to maintain the fire sprinkler system for one of one fire sprinkler systems.
Findings include:
1. Document review and interview on September 22, 2022, at 8:30 a.m., revealed the facility failed to provide documentation of the following sprinkler system defiencies:
a. 8:30 a.m. Three of four quarterly sprinkler inspections were not completed in the last year;
b. 8:30 a.m. The five year internal valve inspection has not been completed since 2016.
Interview with the maintenance director on September 22, 2022, at 8:30 a.m., confirmed the above documentation was not provided at the time of the survey..
Plan of Correction:Note: The office building in which Bucks County Surgical Suites alarm system contractors late 2021. Due to ownership of the contract with the landlord, the contractor was not permitted to forward reports directly to our facility. The inspections in question were performed as required, and documentation was provided to the landlord. The landlord failed to forward all of the reports after multiple requests. All reports have been received and filed at BCSS for review.
POC: Due to contract ownership with the new contractor, Bucks County Surgical was not added to the distribution email for reporting. This has been corrected as of today, October 7, 2022, and all reports are on file at BCSS.
a. The quarterly reports have been performed as required, and the documentation is now onsite.
b. The five year internal inspection was completed on April 4, 2022. The documentation has been received and is now onsite at BCSS.
Follow Up: BCSS has been added to the distribution list for all fire alarm and sprinkler testing moving forward. The administrator works directly with the landlord to ensure the required testing is performed according to NFPA standards, and reported back to the Safety Committee and Medical Executive Committee during quarterly reviews. Any discrepancies with the testing are reported back to assist the committee in formulating a corrective action.
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