Pennsylvania Department of Health
OXFORD VALLEY PAIN & SURGICAL CENTER, INC.
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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OXFORD VALLEY PAIN & SURGICAL CENTER, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: CLASS B ASF - Component: 01 - Tag: 0000

Facility ID# 22821501
Component 01
Main Building

Based on a Relicensure Survey completed on September 18, 2024, it was determined that Oxford Valley Pain & Surgical Center, Inc. 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 III (200), unprotected ordinary building, that is not sprinklered.
Approved as a Class B Ambulatory Surgical Facility.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD General Requirements - Other:

General Requirements - Other
List in the REMARKS section, any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided S-tags, but are deficient.

Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0100

Based on observation and interview, it was determined the facility failed to provide accurate, portable floor plans, as required, affecting the entire facility.

Findings Include:

1. Document review on September 18, 2024, at 8:45 am, revealed the facility failed to provide a set of accurate portable floor plans. The Division of Safety Inspection is requiring that all facilities under our jurisdiction have a portable, accurate floor plan on site to be used during the course of the Life Safety Code Survey.

The Life Safety Code Floor Plans shall include the following:

a. Smoke Barrier Walls (outside wall to outside wall);
b. Fire Barrier Walls (2-hour walls);
c. Horizontal Exits;
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted; and
f. Shafts Walls

Exit interview with the Administrator and Director of Nursing on September 18, 2024, at 10:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 10/08/2024

Corrective Action: An accurate Life Safety Floor Plan to be submitted to Dept of Health Life Safety Division.

Responsible Party: Administrator

Monitoring: To be completed by QAPI committee

28 Pa. Code § 569.2 STANDARD Means of Egress - General:

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: CLASS B ASF - Component: 01 - Tag: 0211
Based on observation and interview, it was determined the facility failed to maintain means of egress free from all obstructions, affecting the entire facility.

Findings include:

1. Observations on September 18, 2024, between 10:12 am and 10:18 am, revealed the below exit doors were locked in the closed position.

a. 10:12 am, Sterile Storage Room exit;
b. 10:18 am, PACU exit.

Exit interview with the Administrator and Director of Nursing on September 18, 2024, at 10:30 am, confirmed that the locked exit doors.

Plan of Correction - To be completed: 10/08/2024

Corrective Action: Sterile Storage Room and PACU exit doors are not fire exits. Signs to be placed on both doors stating, "This Is Not An Exit".

Responsible Party: Administrator

Monitoring: To be completed with monthly Environmental Rounds

28 Pa. Code § 569.2 STANDARD Fire Alarm System - Initiation:

Fire Alarm - Initiation
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit and 200 feet travel distance is not exceeded.
20.3.4.2, 21.3.4.2, 9.6.2

Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0342
Based on observation and interview, it was determined the facility failed to maintain means of fire alarm initiation, affecting the entire facility.

Findings include:

1. Observation on September 18, 2024, at 10:11 am, revealed the fire alarm pull station in the Sterile Storage Room was obstructed by a clean linen cart.

Exit interview with the Administrator and Director of Nursing on September 18, 2024, at 10:30 am, confirmed the obstructed pull station.

Plan of Correction - To be completed: 10/08/2024

Corrective Action: Move the cart in Sterile storage room so as not to obstruct the pull station.

Responsible Party: Administrator

Monitoring: To be completed with monthly Environmental Rounds.

28 Pa. Code § 569.2 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10

Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0355

Based on document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility.

Findings:

1. Document review on September 18, 2024, at 8:45 am, revealed that the following:

a. The facility could not produce documentation of an annual fire extinguisher inspection;
b. The facility could not produce a certificate for the technician conducting the annual fire extinguisher inspections.

Exit interview with the Administrator and Director of Nursing on September 18, 2024, at 10:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 10/08/2024

Corrective Action: Fire extinguishers are currently inspected by our facility staff on a monthly basis via Environmental Rounds. We will request the certificate from the annual inspector from the Fire Extinguisher Inspection company. Certificate to be submitted to Dept of Health Life Safety Division.

Responsible Party: Administrator

Monitoring: Will continue monthly fire extinguisher inspections through Environmental Rounds. We also require Fire Extinguisher company to submit the annual inspector certificate after each annual inspection

28 Pa. Code § 569.2 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2

Observations:
Name: CLASS B ASF - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain and inspect HVAC systems, affecting the entire facility.

Findings include:

1. Document review on September 18, 2024, at 8:45 am, revealed the facility could not provide documentation of a fire/smoke damper inspection performed within the past 4 years.

Exit interview with the Administrator and Director of Nursing on September 18, 2024, at 10:30 am, confirmed the lack of documentation.

Plan of Correction - To be completed: 10/18/2024

Corrective Action: Will schedule an inspection of our facility's fire/smoke dampers from our HVAC company.

Responsible Party: Administrator

Monitoring: To be monitored by our QAPI committee

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