Pennsylvania Department of Health
VALLEY AMBULATORY SURGICAL 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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VALLEY AMBULATORY SURGICAL CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: 02 MAIN BUILDING (FORMER 01 COMPONENT) - Component: 02 - Tag: 0000

Facility ID# 21281501
Component 02
Main Building

Based on a Relicensure Survey completed on November 27, 2023, it was determined that Valley Ambulatory Surgical Center, Llc 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 II (000), unprotected noncombustible building, that is fully sprinklered.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Sprinkler System - Maintenance and Testing:

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: 02 MAIN BUILDING (FORMER 01 COMPONENT) - Component: 02 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system that provides sprinkler protection throughout the facility.

Findings include:

1. Document review and observation on Novemeber 27, 2023, between 10:30 am, and 11:30 am, revealed the required five inspections of the sprinkler system were over due, including gauges.

Interview with the facility representative on November 27, 2023, at 11:30 am, confirmed the five year inspections were not completed and were now over due.

Plan of Correction - To be completed: 12/08/2023

The assistant administrator of the facility will obtain the required 5 year sprinkler system and gauge inspection. This date will be documented in the governing body quarterly meetings to insure this deficiency does not recur.

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