Pennsylvania Department of Health
TRI-COUNTY OUTPATIENT SURGICAL FACILITY, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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TRI-COUNTY OUTPATIENT SURGICAL FACILITY, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on May 8, 2024, at Tri-County Outpatient Surgical Facility, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID# 04501500
Component 01
Main Building

Based on a Recertification/Relicensure Survey completed on May 8, 2024, it was determined that Tri County Outpatient Surgical Facility was not in compliance with the following requirements of the Life Safety Code for an existing 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 one-story, Type V (000), unprotected wood frame building, with a basement, that is not sprinklered

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

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, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system in one instance, affecting the entire facility.

Findings include:

1. Review of documentation on May 8, 2024, at 9:35 a.m., revealed there were multiple unsealed ceiling penetrations in the electrical room in the basement.

Interview with the Facility Administrator on May 8, 2024, at 9:35 a.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 06/30/2024

The facility director shall ensure that sealing of ceiling penetrations in the electrical room is completed by corrective action date to ensure the safety of the fire alarm system.

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