INTEGRATED SURGICAL INSTITUTE, LLC
Building Inspection Results For:
There are 4 surveys for this facility. Please select a date to view the survey results.
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Initial Comments:
Name - ENTIRE BUILDING Component - 01
Facility ID #50711501
Component 01
Main Building
Based on a Relicensure Survey completed on April 13, 2023, it was determined that Integrated Surgical Institute, Llc 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 V (000), unprotected wood frame structure, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Electrical Systems -Essential Electric System
Name - ENTIRE BUILDING 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 document review and interview, it was determined the facility failed to provide documentation of emergency generator fuel sample quality results, affecting the entire facility.
Findings include:
1. Review of documentation on April 13, 2023, between 10:00 AM and 11:30 AM, revealed the facility failed to provide documentation verifying the quality of the emergency fuel reserve, within the previous twelve months.
Interview with the Chief Administrative Officer on April 13, 2023, at 11:30 AM, confirmed the lack of documentation.
Plan of Correction:The administrator will contract Fuel testing for the emergency generator by 5/31/2023 and then annually with quarter 2 preventative maitainence. The administrator will check during Q3 and Q1 to ensure that testing has been completed and results are filed in Life Safety document binder.
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