QA Investigation Results

Pennsylvania Department of Health
BMMSA HEART AND VASCULAR CENTER OF THE MAIN LINE
Building Inspection Results

BMMSA HEART AND VASCULAR CENTER OF THE MAIN LINE
Building Inspection Results For:


There are  2 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - TENANT SPACE Component - 01

Facility ID# 50811501
Component 01

Based on a Relicensure Survey completed on February 16, 2023, it was determined that Bmmsa Heart and Vascular Center of the Main Line was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.

This is a three-story, Type II (000), unprotected, non-combustible construction, which is fully sprinklered.








Plan of Correction:




NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance

Name - 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 document review and interview, it was determined the facility failed to maintain and inspect the fire alarm system, affecting the entire component.

Findings include:

1. Document review on February 16, 2023, at 8:00 am, revealed the facility could not provide the following documentation:

a. Semi-annual fire alarm inspection within 6 months of the October 18, 2022 Report;
b. Smoke detector sensitivty testing within 12 months of installation.

Exit interview with the Administrator and the Facilities Manager on February 16, 2023, at 10:00 am, confirmed the lack of documentation.




Plan of Correction:

1a. The semi-annual fire alarm visual inspection has been completed on February 28, 2023. The contract with the vendor was reviewed and updated to reflect the ongoing testing and to assure it does not get missed again.
In addition, it has been added to the maintenance supervisor calendar as well as the administrator calendar to assure the vendor will be scheduling these routine inspections as required. The administrator verified this semi-annual inspection is in the contract in accordance with the NFPA Fire testing and maintenance.
1b- Smoke detector sensitivity test was completed on 2/28/23, to correct this deficiency. We passed the sensitivity test. This was completed as part of the fire alarm security inspection completed at the ASC as planned on that date.
It has been added to the maintenance supervisor calendar as well as the administrator calendar to assure the vendor will be scheduling the smoke detector sensitivity test every two years from the 2/28/23 date. It has also been verified by the administrator that it has been added to our contract with the vendor in accordance with the NFPA Fire Alarm Testing and Maintenance Standards.
As a final on-going assurance, the BMMSA Heart & Vascular Center QA/PI program workplan for 2023 has been updated to include a month and quarter that all of the deficiencies from this state survey will be monitored by the committee




NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - 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 document review and interview, it was determined th facility failed to maintain and inspect the sprinkler system, affecting two of four inspections.

Findings include:

1. Document review on February 16, 2023, at 8:00 am, revealed the facility could not produce a sprinkler inspection for the 2nd quarter of 2022.

Exit interview with the Administrator and the Facilities Manager on February 16, 2023, at 10:00 am, confirmed the lack of documentation.




Plan of Correction:

1.There was an inconsistency in the quarterly sprinkler system testing. This was identified prior to the state inspection on 2/16/23. The inspection was done on 11/3/22 and again on 2/1/23 which has gotten us into a quarterly schedule with our vendor.
We have put a plan in place to assure the company puts us on their schedule for the next quarter inspection immediately following the current quarter inspection completion. This will help assure the vendor's ability to meet the 3 month window for each subsequent inspection. The next quarterly inspection is scheduled for 5/1/23.
The administrator has verified that the contract does state quarterly inspections.
Moving forward the dates will be verified with the vendor and placed on the maintenance supervisor and the administrator calendars. The maintenance supervisor will review the quarterly inspection report and discuss any findings with the administrator.
As a final on-going assurance, the BMMSA Heart & Vascular Center QA/PI program workplan for 2023 has been updated to include a month and quarter that all of the deficiencies from this state survey will be monitored by the committee





NFPA 101 STANDARD
Electrical Systems-Essential Electric System

Name - TENANT SPACE 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 maintain and inspect the emergency generator, affecting the entire facility.

Findings include:

1. Document review on February 16, 2023, at 8:00 am, revealed the facility could not provide the following documentation:

a. Natural Gas reliability letter;
b. Monthly testing of battery electrolyte specific gravity or conductance.

Exit interview with the Administrator and the Facilities Manager on February 16, 2023, at 10:00 am, confirmed the lack of documentation.



Plan of Correction:

1a. The Natural Gas service reliability letter was received from PECO our natural gas supplier, on 2/21/23 and has been entered into our permanent files. The letter verifies that unplanned outages in 2022 occurred for only 0.135% of PA PECO customers. which did not affect this site. PECO's natural gas is regulated by the PA public utility commission, and therefore, there is significant protection to PECO facilities from floods, storms, and damage from freezing. (Earthquake damage in Pennsylvania is rare).
This report will be requested annually from PECO by the maintenance supervisor and both the Administrator and maintenance supervisor have added this to the calendar to request a new natural gas reliability letter in December 2023.
1b.The weekly testing of the generator is done by our maintenance supervisor and the monthly testing of the generator have been completed by an outside vendor, with whom we have a contract. The batteries we have are sealed and the vendor had not done additional testing on them.
The monthly inspection now includes a conductance test on the center's 2 batteries. This was completed on 2/27/23 with our full generator testing, and will continue to be checked monthly by the contracted company. The test on 2/27/23 verified the 2 batteries met the range requirements.
The conductance test has been added to the vendor contract and therefore moving forward will be part of the generator inspection. The maintenance supervisor will review the monthly report from our vendor to assure the conductance testing is completed, and will follow-up with the Administrator. Both the maintenance supervisor and the administrator will include the inspection dates on their calendars.
As a final on-going assurance, the BMMSA Heart & Vascular Center QA/PI program workplan for 2023 has been updated to include a month and quarter that all of the deficiencies from this state survey will be monitored by the committee.