Nursing Investigation Results -

Pennsylvania Department of Health
SUSQUEHANNA VALLEY SURGERY CENTER, L.L.C.
Building Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SUSQUEHANNA VALLEY SURGERY CENTER, L.L.C.
Inspection Results For:

There are  19 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.
SUSQUEHANNA VALLEY SURGERY CENTER, L.L.C. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID #11761500
Component 01
Main Building

Based on a Relicensure Survey completed on February 24, 2020, it was determined that Susquehanna Valley Surgery Center, L.L.C. was not in compliance with the following requirements of the Life Safety Code for an existing ambulatory health care occupancy.

This is a two-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.

The Ambulatory Surgery Facility is located in the basement.



 Plan of Correction:


28 Pa. Code 569.2 STANDARD Means of Egress - General:State only Deficiency.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, on one of three floors within the component.

Findings include:

1. Observation on February 24, 2020, at 9:45 AM revealed the stairtower door by PACU 1 had a gap along the top greater than 1/8 inch, and holes from old hardware.

Interview with the Facilities Manager on February 24, 2020, at 9:45 AM confirmed the rated door exceeded the allowed gap margins.



 Plan of Correction - To be completed: 04/30/2020

A replacement stairtower door was ordered on 03/02/2020. Expected arrival date given upon order was a minimum of five weeks. The door will be installed by UPMC Pinnacle Technical Services Department within one week of arrival. No later than 4/30/2020.

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