Pennsylvania Department of Health
GSH OUTPATIENT SURGERY CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GSH OUTPATIENT SURGERY CENTER
Inspection Results For:

There are  22 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GSH OUTPATIENT SURGERY CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID #05781500
Component 01
Main Building

Based on a Relicensure Survey completed on October 25, 2023, it was determined that GSH Outpatient Surgery Center was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.

This is a one-story, Type V(000), unprotected wood frame structure, without a basement, which is fully sprinklered.



 Plan of Correction:


28 Pa. Code 569.2 STANDARD Sprinkler System - Maintenance and Testing:State only Deficiency.
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:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review, observation and interview, it was determined the facility failed to provide quarterly inspection documentation and sprinkler piping system, to be free of extraneous weight, affecting the entire component.

Findings include:

1. Review of documentation on October 25, 2023, between 9:00 AM and 10:30 AM, revealed the facility lacked documentation for the 2nd quarter of 2023 inspection, of the dry sprinkler system.

Interview at the time of the exit conference with the Regulatory Compliance Coordinator, Accreditation & Licensure Manager, Emergency Management Manager, Senior Properties Coordinator and Facilities Technician on October 25, 2023, at 1:30 PM, confirmed the facility could not provide all quarterly inspection reports.


2. Observation on October 25, 2023, between 11:40 AM and 11:50 AM, revealed various items laying across the sprinkler piping system, at the following locations:

a. 11:40 AM, above ceiling, corridor, by the Conference Room, various tele-communication wires;
b. 11:50 AM, above ceiling, above smoke doors, in the corridor by the Housekeeping Closet, various tele-communication wires and rigid pipes.

Interview at the time of the exit conference with the Regulatory Compliance Coordinator, Accreditation & Licensure Manager, Emergency Management Manager, Senior Properties Coordinator and Facilities Technician on October 25, 2023, at 1:30 PM, confirmed the sprinkler piping system was subject to extraneous weight.



 Plan of Correction - To be completed: 11/03/2023

Plan of Correction:

1. Work order # 202329818was entered on October 23, 2023, for quarterly inspection of the dry sprinkler system to be completed by Commonwealth Fire Protection (CFP) to ensure quarterly inspections are completed.

2. Work order # 2023313083 was entered on November 2, 2023, to evaluate all current above ceiling areas to ensure compliance with no wires laying on the sprinkler piping system.


Systemic Changes Implemented to Prevent Recurrence of the Deficiencies:

1. Quarterly report from Commonwealth Fire Protection (CFP) will be sent by senior property coordinator to manager of Accreditation and Licensure for validation that inspection was completed.
2. The above ceiling access permit process will be instated. Any vendor or WellSpan department doing work above the ceiling will have the planned above ceiling work reviewed and issued a permit. When the work is completed, engineering will complete a visual inspection of the above ceiling work to ensure compliance. Monthly report of permit process sent to manager of Accreditation and Licensure.

Person Responsible for Corrective Actions:

Senior Properties Coordinator

Method for Monitoring:

PM tasks as described above.

Frequency of Monitoring: 1. Quarterly 2. Monthly

Measure of Effectiveness:

100% of PM activities will demonstrate compliance with NFPA Standards.

Corrective actions will be determined effective after three consecutive months of 100% compliance. After sustained compliance is achieved, monitoring will transition to checks completed during Environment of Care Rounds. Monitoring results will be provided by the Sr. Properties Coordinator and reported monthly to the Surgery Center's Quality Management
28 Pa. Code 569.2 STANDARD HVAC:State only Deficiency.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review, observation and interview, it was determined the facility lacked documentation, verifying the 4-year fire damper maintenance and exercise was performed, affecting the entire component.

Findings include:

1. Review of documentation on October 25, 2023, between 9:00 AM and 10:30 AM, revealed the facility failed to provide documentation, for the 4-year fire damper exercise and maintenance.

Interview at the time of the exit conference with the Regulatory Compliance Coordinator, Accreditation & Licensure Manager, Emergency Management Manager, Senior Properties Coordinator and Facilities Technician on October 25, 2023, at 1:30 PM, confirmed the lack of documentation.



 Plan of Correction - To be completed: 11/03/2023

Plan of Correction:

Work order # 2023313109 was entered on November 2, 2023, to set up a PM (preventative maintenance) and inspection of the fire dampers to be performed every 4 years.

Systemic Changes Implemented to Prevent Recurrence of the Deficiencies:

Report will be sent to manager of Accreditation and Licensure for validation that inspection was completed.

Person Responsible for Corrective Actions:

Senior Properties Coordinator

Method for Monitoring:

Completed report will be sent to and reviewed by manager of Accreditation and Licensure.

Frequency of Monitoring:

Quadrennial

Measure of Effectiveness:

100% of PM activities will demonstrate compliance with NFPA Standards.

Corrective actions will be determined effective after three consecutive months of 100% compliance. After sustained compliance is achieved, monitoring will transition to checks completed during Environment of Care Rounds. Monitoring results will be provided by the Sr. Properties Coordinator and reported monthly to the Surgery Center's Quality Management Council (QMC) by the Manager Accreditation and Licensure.


28 Pa. Code 569.2 STANDARD Gas and Vacuum Systems - Warning Systems:State only Deficiency.
Gas and Vacuum Piped Systems - Warning Systems
All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable.
5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0904

Based on document review and interview, it was determined the facility failed to maintain medical gas system components in operable condition, affecting the entire facility.

Findings include:

1. Review of documentation on October 25, 2023, between 9:00 AM and 10:30 AM, revealed the annual medical gas inspection report dated May 25, 2023, listed a low vacuum alarm deficiency.

Interview at the time of the exit conference with the Regulatory Compliance Coordinator, Accreditation & Licensure Manager, Emergency Management Manager, Senior Properties Coordinator and Facilities Technician on October 25, 2023, at 1:30 PM, confirmed the low vacuum alarm had not been repaired, at the time of survey.



 Plan of Correction - To be completed: 11/03/2023

Plan of Correction:

Work order # 202313070 was entered on November 2, 2023, for vendor Sherman Engineering to correct the medical gas inspection failures.

Systemic Changes Implemented to Prevent Recurrence of the Deficiencies:

Report from Sherman Engineering will be sent to manager of Accreditation and Licensure for validation that corrections were completed.

Person Responsible for Corrective Actions:

Senior Properties Coordinator

Method for Monitoring:

Completed report of corrections will be sent to and reviewed by manager of Accreditation and Licensure.

Frequency of Monitoring:

Monthly

Measure of Effectiveness:

100% of PM activities will demonstrate compliance with NFPA Standards.

Corrective actions will be determined effective after three consecutive months of 100% compliance. After sustained compliance is achieved, monitoring will transition to checks completed during Environment of Care Rounds. Monitoring results will be provided by the Sr. Properties Coordinator and reported monthly to the Surgery Center's Quality Management Council (QMC) by the Manager Accreditation and Licensure.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port