Initial Comments:
Name - CLASS B ASF Component - 01
Facility ID# 50821501
Component 01
Building 01
Based on a Relicensure Survey completed on December 27, 2023, it was determined that Cherry Tree Surgical, 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, without a basement, which is not sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Emergency Lighting
Name - CLASS B ASF Component - 01
Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
Observations:
Based on document review and interview, it was determined the facility failed to provide documentation of the monthly and annual battery-powered emergency light testing, affecting the entire component.
Findings include:
1. Review of documentation on December 27, 2023, between 9:30 AM and 10:30 AM, it was revealed the facility failed to document monthly and annual testing of battery powered emergency lighting sources.
Interview at the time of the exit conference with the Surgical Coordinator and Surgical Tech on December 27, 2023, at 12:00 PM, confirmed the facility could not provide documentation for the installed back-up emergency lighting tests.
Plan of Correction:1. The log for the monthly and annual battery-powered back up testing has been created and it currently being utilized.
2. This was corrected on 01/13/2024.
3. A list of all pertinent logs has been created and will be reviewed monthly by the administrator.
4. The list of logs will be monitored monthly by the administrator to ensure they are completed timely.
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - CLASS B ASF 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 provide documentation, verifying the annual, semiannual and 2-year sensitivity inspection had been performed on the fire alarm system, affecting the entire component.
Findings include:
1. Review of documentation on December 27, 2023, between 9:30 AM and 10:30 AM, revealed the facility lacked documentation, verifying the fire alarm system had an annual functional and semiannual visual inspections, in the last twelve months.
Interview with the Surgical Coordinator and Surgical Tech on December 27, 2023, at 12:00 PM, confirmed the lack of documentation for any fire alarm inspections, in the last twelve months.
2. Review of documentation on December 27, 2023, between 9:30 AM and 10:30 AM, revealed the facility failed to provide documentation, verifying the sensitivity of smoke detectors, installed throughout the facility, had been tested, within the past two years.
Interview with the Surgical Coordinator and Surgical Tech on December 27, 2023, at 12:00 PM, confirmed the lack of documentation, verifying the sensitivity of smoke detectors, installed throughout the facility, had been tested, within the previous two years.
Plan of Correction:1. The fire alarm contract is being completed to include the annual, semiannual and 2-year sensitivity testing and inspection. These requirements have been added to the list of monthly reviews conducted by the administrator.
2. This will be completed by 2/01/2024.
3. The semiannual, annual and two-year inspections and sensitivity test have been added to the list of logs that the administrator will review on a monthly basis to ensure they are completed timely.
4. The administrator has a comprehensive list of logs to review on a monthly basis to ensure nothing is missed and all equipment is maintained appropriately.
NFPA 101 STANDARD
Electrical Systems-Essential Electric System
Name - CLASS B ASF 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 required maintenance and testing documentation, for the emergency generator, which serves the entire component.
Findings include:
1. Review of documentation on December 27, 2023, between 9:50 AM and 10:30 AM, revealed the facility lacked documentation, for the following:
a. 9:50 AM, one full year, weekly maintenance;
b. 10:30 AM, one full year, monthly maintenance, 30-minute load w/transfer switch.
Interview at the time of the exit conference with the Surgical Coordinator and Surgical Tech on December 27, 2023, at 12:00 PM, confirmed the lack of documentation, for the emergency generator.
Plan of Correction:1. The generator logs for weekly and monthly maintenance have been started and a 30-minute load test w/ transfer switch has been added to the monthly run.
2. This will be completed on 01/26/2024.
3. The weekly and monthly logs for the generator have been added to the list of logs that the administrator will monitor monthly to ensure they are completed timely.
4. The administrator will review the monthly list of logs to ensure nothing will be missed and all appropriate systems are maintained according to policy.
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