Initial Comments:
Name - SUITE A-14 Component - 01
Facility ID# 50611501
Component 01
Main Building
Based on a Relicensure Survey completed on October 2, 2023, it was determined that TMA Vascular Center 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 noncombustible building, without a basement, that is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - SUITE A-14 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 document review and interview, the facility failed to meet the requirements for sprinkler system testing and maintenance for one of one system.
Findings include:
1. Document review on October 2, 2023 at 8:50 a.m., revealed the facility was unable to provide the documentation for the five-year sprinkler gauge replacement (last documented in 2017).
Interview with Facility Staff on October 2, 2023, at 10:30 a.m., confirmed the above listed sprinkler deficiency.
Plan of Correction:A staff meeting will be held on 10/13/2020 to review the need to change the sprinkler gauges every 5 years.
The sprinkler gauges were changed on 10/5/2023 by Preferred Inspection Testing Maintenance.
The Director of Operations/Designee, will audit for compliance.
The Governing Body will maintain oversight per the QA schedule.
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - SUITE A-14 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 and interview, it was determined the facility failed to perform the required annual fuel quality testing of the emergency generator, affecting the entire facility. Maintenance shall be in accordance with NFPA 110, 8.3.8
Findings include:
1 Observation and review of documentation on October 2, 2023, at 8:45 a.m., revealed the facility lacked documentation to confirm if the annual fuel quality test had been performed.
Interview with Facility Staff on October 2, 2023, at 10:30 a.m., confirmed the above listed emergency generator fuel quality testing deficiency.
Plan of Correction: A staff meeting will be held on 10/13/2020 to review the need to obtain annual fuel quality testing of the emergency generator.
The testing is scheduled to be performed on 10/31/2023 and will be performed annually thereafter.
The Director of Operations/Designee, will audit for compliance.
The Governing Body will maintain oversight per the QA schedule.
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