Pennsylvania Department of Health
SOUTH HILLS ENDOSCOPY CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SOUTH HILLS ENDOSCOPY CENTER - 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 June 3, 2025, at South Hills Endoscopy Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.

Plan of Correction:

Initial comments:Name: A0101 - Component: 01 - Tag: 0000

Facility ID# 20281501
Component 01
Main Building

Based on a Recertification/Relicensure Survey completed on June 3, 2025, it was determined that South Hills Endoscopy 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 42 CFR 416.44(b).

This is a one-story, Type II (000), unprotected noncombustible building, without basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

Gas Equipment - Cylinder and Container Storage
*Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
*Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hour fire protection rating.
*Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: A0101 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to properly store medical gas cylinders in one instance, affecting one of two smoke compartments.

Findings include:

1. Observation on June 3, 2025, at 9:15 a.m., revealed an unsecured medical gas cylinder in the medical gas room.

Interview with the Facility Staff on June 3, 2025, at 11:00 a.m., confirmed there was an unsecured cylinder in the medical gas room.

Plan of Correction - To be completed: 06/11/2025

Immediate correction of the unsecured tank were properly secured per standards on 6/3/2025. A new form was created and approve by the governing body to have GI techs sign off daily to ensure tanks are stored in the gas tank room per standard. An audit will take place monthly to ensure 100% compliance is achieved. The audit will be performed monthly x 1 year. If 100% compliance is achieved, periodic random audits will be performed.

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