Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on November 12, 2024, at Children's Dental Surgery of Philadelphia, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - 01 - Component - 01
Facility ID# 50641501
Component 01
Main Building
Based on a Recertification/Relicensure Survey completed on November 12, 2024, it was determined that Children's Dental Surgery of Philadelphia, 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).
This is a three-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - 01 - 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 the Sprinkler system, affecting one of two FDC connections.
Findings include:
Observation on November 12, 2024, at 10:00 a.m., revealed the Fire Department Connection (FDC) was missing its protective caps, front entrance standpipe.
Exit Interview with the Administrator on November 12, 2024, at 11:00 a.m., confirmed the missing FDC caps.
Plan of Correction:Observation 0353 notes that the facility failed to maintain the sprinkler system affecting one of the two FDC connections which was missing its protective cap on the front entrance standpipe. The Commonwealth Building is the building with which the facility operates. The Commonwealth Building Manager has replaced the missing FDC cap on 11/12/24.
The Administrator has coordinated with the Commonwealth building manager to add FDC protective cap check to the monthly building check to prevent future occurrence of uncapped FDC connections. The monthly check list is now updated to include FDC fire cap checks and available upon request.
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - 01 - 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 the entire facility.
Findings include:
Document review on November 12, 2024, at 9:30 a.m., revealed annual fuel quality testing results for the emergency generator's diesel fuel were not available for review at time of survey.
Exit Interview with the Administrator on November 12, 2024, at 11:00 a.m., confirmed the missing documentation.
Plan of Correction:Observation 0918 revealed the annual fuel quality testing results for the emergency generator's diesel fuel was not available for review at time of survey.
Curtis Power Solutions is the contracted generator maintenance company for the Children's Surgery Center of Philadelphia. The Administrator has received the generator fuel report on 11/13/24. It was noted by Curtis Power Solutions that the fuel quality sample failed testing. Children's Dental Surgery Center of Philadelphia has accepted and signed Curtis Power Solutions work order to drain, treat and filter fuel to meet fuel testing standards. A copy of the signed work order is available upon request.
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