Nursing Investigation Results -

Pennsylvania Department of Health
UOC SURGICAL SERVICES, LTD.
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
UOC SURGICAL SERVICES, LTD.
Inspection Results For:

There are  20 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.
UOC SURGICAL SERVICES, LTD. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 15341501
Component 01
Main Building

Based on a Relicensure Survey completed on February 19, 2020, it was determined that UOC Surgical Services, LTD., 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 building, that is fully sprinklered.




 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 means of egress in multiple locations, affecting one of two floors.

Findings include:

1. Observation on February 19, 2020, at 8:50 a.m., revealed the facility lacked annual fire door maintenance and inspection data.

Exit interview with facility representative #1 on February 19, 2020, between 9:40 a.m. and 9:45 a.m., confirmed the means of egress deficiency.



 Plan of Correction - To be completed: 02/28/2020

Following our February 19, 2020 annual Building and Life Safety inspection, all fire door enclosures were numbered throughout the facility and inspected on February 28, 2020 by a third party contractor.

We have added this to our annual facility inspection checklist in accordance with NFPA 80 and NFPA 101 annual fire door inspection standards and will document all future inspections on the proper forms.
28 Pa. Code 569.2 STANDARD Gas and Vacuum Systems - Other:State only Deficiency.
Gas and Vacuum Piped Systems - Other
List in the REMARKS section, any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided S-Tags, but are deficient.
Chapter 5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0902

Based on observation and interview, it was determined the facility failed to maintain one medical gas manifold room in one location, affecting one of two floors.

Findings include:

1. Observation on February 19, 2020, revealed the medical gas manifold room lacked dedicated mechanical exhaust (former dedicated exhaust duct work was cut off at a height of approximately ten feet and new duct opening for manifold room exhaust was cut into existing, non-dedicated exhaust duct).

Exit interview with facility representative #1 on February 19, 2020, between 9:40 a.m. and 9:45 a.m., confirmed the medical gas manifold room lacked dedicated mechanical exhaust.



 Plan of Correction - To be completed: 05/04/2020

Existing non-dedicated exhaust duct will be capped and replaced with new dedicated mechanical ventilation system with explosion proof exhaust fan which will be vented directly to the exterior of the facility to comply with current NFPA 99 standards.

Contractors for this project have been selected and is anticipated to be completed by May 4, 2020.

The operations of the new mechanical ventilation system for the medical gas room will be placed on our existing Quarterly Preventative Maintenance checklist for regular observation and operations of the system.


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