Pennsylvania Department of Health
RADIANCE - A PRIVATE OUTPATIENT SURGERY CENTER, LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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RADIANCE - A PRIVATE OUTPATIENT SURGERY CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING - Component: 02 - Tag: 0000

Facility ID# 17601501
Component 02
Main Building

Based on a Relicensure Survey completed on September 12, 2023, it was determined that Radiance-A Private Outpatient Surgery Center 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 28 Pa Code 569.2.

This is a two-story, Type III (200), unprotected ordinary building, without a basement, that is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7

Observations:
Name: MAIN BUILDING - Component: 02 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting the entire facility.

Findings include:

1. Observation on September 12, 2023, at 10:25 a.m., revealed the door seperating the clean utility to central sterile was not equipped with a self closure.

Interview with the Director of Nursing and the Maintenance Manager on September 12, 2023, at 11:30 a.m., confirmed the hazardous area enclosure deficiency.

Plan of Correction - To be completed: 09/19/2023

On 9-16-23 the facility manager installed an automatic self door closure on the door separating the clean utility to central sterile.

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