Initial Comments:
Name - 01 - Component - 01
Facility ID# 50641501
Component 01
Main Building
Based on a Relicensure Survey conducted on November 16, 2022, it was determined Children's Dental Surgery Of Philadelphia was not in compliance as related to the 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 construction, with a basement, which is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - 01 - Component - 01
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided S-tags, but are deficient.
Observations:
Based on document review and interview, it was determined the facility failed to provide a set of accurate portable life safety floor plans. The Division of Safety Inspection requires all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey; failed to obtain required Pennsylvania Department of Health plan approval for renovations, affecting the entire facility.
Findings include:
1. Document review on November 16, 2022, at 8:30 a.m., revealed the facility could not provide a set of accurate portable life safety floor plans.
The Life Safety Code Floor Plans shall include the following:
a. Smoke Barrier Walls;
b. Fire Barrier Walls;
c. Horizontal Exits;
d. Hazardous Areas;
e. Required Exits should be clearly noted; and
f. Shafts Walls.
Exit interview with the Administrator on November 16, 2022, at 10:30 a.m., confirmed the lack of accurate, portable floor plans.
Plan of Correction:Observation 0100 notes that the facility failed to provide a set of accurate portable Life Safety Floor Plans. There are blueprints available onsite as well as a pdf stored on the computer that I will attach in an email. The administrator was educated where the pdf is stored if a digital copy is required in the future. The hard copy and pdf copy of the blueprint was on site and shared during the survey.
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 document review, observation and interview, it was determined the facility failed to maintain the sprinkler system, affecting the entire facility.
Findings Include:
1. Document review on November 16, 2022, at 8:30 a.m., revealed the facility could not provide documentation a five year internal valve and piping inspection was performed.
Exit interview with the Administrator on November 16, 2022, at 10:30 a.m., confirmed the lack of documentation.
2. Observation on November 16, 2022, at 10:00 a.m., revealed the sprinkler gauges were dated 2015 and were not replaced or re-calibrated within the past five years.
Exit interview with the Administrator on November 16, 2022, at 10:30 a.m., confirmed the outdated sprinkler gauges.
Plan of Correction:1.Observation 0353 notes that the facility could not provide documentation of a five year internal valve and piping inspection being performed.
The facility has not been operational for five years. The Commonwealth Building is the building in which the facility operates. The Commonwealth Building Manager has provided an internal valve and piping inspection performed in February 2020 and will be attached to an email.
The Administrator will coordinate with Commonwealth Building Manager in providing five year valve and piping inspection documentation.
2.Observation 0353 revealed the sprinkler gauges were dated 2015 and were not replaced or recalibrated within the past five years.
The Commonwealth Building is the building in which the facility operates. The Commonwealth Building Manager has provided documentation of new fire pump gauges being installed on 12/15/2022 and will be attached in an email.
The Administrator will coordinate with Commonwealth Building Manager on an annual basis to ensure fire pump gauges remain up to date.
NFPA 101 STANDARD
HVAC
Name - 01 - Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
Observations:
Based on document review, it was determined the facility failed to maintain HVAC systems, affecting the entire facility.
Findings include:
1. Document review on November 16, 2022, at 8:30 a.m., revealed the facility could not provide documentation showing the fire/smoke dampers had been inspected and exercised one year after installation.
Exit interview with the Administrator on November 16, 2022, at 10:30 a.m., confirmed the lack of documentation.
Plan of Correction:Observation 0521 revealed the facility could not provide documentation showing the fire/smoke dampers had been inspected and exercised one year after installation.
The Administrator has retained Lor-Mar Mechanical Services and is coordinating with the Commonwealth Building Management to inspect all the dampers in Children's Surgery Center by February 28, 2023.
The Commonwealth Building is the building in which the surgery center is located.
NFPA 101 STANDARD
Electrical Systems - Essential Electric Sys
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 to 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 document review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility.
Findings include:
1. Document review on November 16, 2022, at 8:30 a.m., revealed the facility could not provide documentation monthly electrolyte specific gravity or conductance testing was performed.
Exit interview with the Administrator on November 16, 2022, at 10:30 a.m., confirmed the lack of documentation.
Plan of Correction:Observation 0918 revealed the facility could not provide documentation monthly electrolyte specific gravity or conductance testing was performed.
Emergency Systems is the contracted generator maintenance company for the Children's Surgery Center. The Administrator has been instructed by Emergency Systems to purchase equipment that will allow for a monthly electrolyte specific gravity or conductance testing to be performed. Once the equipment arrives, a technician from Emergency Systems will provide onsite training. Upon completion of training, the Administrator will begin monthly electrolyte specific gravity/conductance testing and will have a printed receipt documenting monthly testing is being completed.
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