Pennsylvania Department of Health
ST. LUKE'S GRAND VIEW AMBULATORY SURGERY CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 14 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.


ST. LUKE'S GRAND VIEW AMBULATORY SURGERY CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0000

Facility ID# 24661501
Component 01
Main Building

Based on a Relicensure Survey completed on January 7, 2026, it was determined that St. Luke's Grand View Ambulatory Surgery Center, was not in compliance with the following requirements of the Life Safety Code for a new Ambulatory health care occupancy.

This is a one-story, Type V (000), unprotected wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm Systems - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5

Observations:
Name: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0345

Based on document review, observation, and interview, it was determined the facility failed to maintain testing and inspection of the fire alarm system, affecting the entire facility.

Findings include:

1. Document review on January 7, 2026, at 9:00 a.m., revealed the facility could not provide the following tests and inspections:
a. Annual testing and inspection.
b. Semi-annual visual inspection.

Exit Interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed the missing documentation.

2. Observation on January 7, 2026, at 9:40 a.m., revealed the fire alarm panel was in trouble mode.

Exit Interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed the fire alarm panel was in trouble mode.

Plan of Correction - To be completed: 02/20/2026

1. Grand View Surgery Center was unable to provide the annual fire alarm testing as well as the semiannual visual inspection. Everon performed quarterly visual and functional testing on 2/26/26, 5/21/26, 8/6/26, and 11/12/26. This documentation was not immediately available at the time of the survey. The report has been placed in the Life Safety binder.
2. In addition, the fire alarm panel was in trouble mode. The building manager has scheduled Everon and TKE elevator to be onsite to address this issue on 2/2/26.
Moving forward, the Grand View facility director has implemented a documentation system to ensure all fire alarm testing and documentation are immediately accessible. The Grand View facility director will also perform routine rounding of the fire panel during environmental rounds to ensure continued compliance. This information will also be reviewed at the quarterly Safety Committee meeting.

NFPA 101 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: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0353

Based on document review, observation, and interview, it was determined the facility failed to maintain the sprinkler system, affecting the entire facility.

Findings include:

1. Document review on January 7, 2026, at 9:00 a.m., revealed the facility could not produce documentation showing the 5-year pipe and valve inspection.

Exit Interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed the missing documentation.

2. Observation on January 7, 2026, at 9:30 a.m., revealed a concealed sprinkler head that was dislodged from the ceiling tile, Mechanical Room near the front hallway.

Exit Interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed the deficient sprinkler head.

Plan of Correction - To be completed: 02/20/2026

1. Grand View Surgery center completed the required five-year sprinkler pipe and valve internal inspection on August 9, 2023. This documentation was not immediately available at the time of the survey. The report has been placed in the Life Safety binder.

2. The concealed sprinkler head that was found dislodged from the ceiling tile in the mechanical room was repaired the same day as the inspection.

Moving forward, the Grand View facility director has implemented a documentation system to ensure all sprinkler system inspection documentation are immediately accessible. St. Luke's Grand View facility engineering will also perform routine rounding of the sprinkler heads during environmental rounds to ensure continued compliance. This information will be reviewed at the quarterly Safety Committee meeting.

NFPA 101 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: HARLEYSVILLE OUTPATIENT CENTER - 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 January 7, 2026, at 9:00 a.m., revealed the following missing documentation:

a. Annual fire extinguisher inspection.
b. Certificate for the technician conducting the annual fire extinguisher inspections.

Exit Interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 02/20/2026

The facility completed the required annual fire extinguisher inspection on April 25, 2025. This documentation was not immediately available at the time of the survey. The report has been placed in the Life Safety binder. We also obtained a copy of a certificate from the technician who conducted the annual fire extinguisher inspection. Moving forward, the St. Luke's Grand View facility director has implemented a documentation system to ensure all fire extinguisher inspection documentation along with the technician's certificate are immediately accessible. This information will be reviewed at the quarterly Safety Committee meeting.

NFPA 101 STANDARD Utilities - Gas and Electric:

Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2

Observations:
Name: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0511

Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting one of two smoke zones.

Findings include:

1. Observation on January 7, 2026, at 9:30 a.m., revealed storage within three feet of the electrical panel in the Mechanical Room near front hallway.

Exit Interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed the obstructed electrical panel.

Plan of Correction - To be completed: 02/20/2026

St. Luke's Grand View engineering relocated the storage and addressed this issue on 1/8/26. St. Luke's Grand View facility engineering will also perform routine environmental rounds to ensure continued compliance. This information will also be reviewed at the quarterly Safety Committee meeting.

NFPA 101 STANDARD Gas and Vacuum Piped Systems - Maintenance:

Gas and Vacuum Piped Systems - Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

Observations:
Name: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0907

Based on observation and interview, the facility failed to inspect and maintain the medical gas manifold system, affecting the entire facility.

Findings include:

1. Observation on January 7, 2026, at 9:00 a.m., revealed the facility could not produce the annual inspection and testing report of the Central Supply, Vacuum and related alarms at the time of survey.

Exit Interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 02/20/2026

MJC Medical Services performed an annual inspection on 1/16/26. Moving forward, the St. Luke's Grand View facility director has implemented a documentation system to ensure all Central Supply, Vacuum, and related alarm inspection documentation are immediately accessible. St. Luke's Grand View facility engineering will also perform routine environmental rounds to ensure continued compliance. This information will be reviewed at the quarterly Safety Committee meeting.

NFPA 101 STANDARD Electrical Systems-Essential Electric System:

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10-seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: HARLEYSVILLE OUTPATIENT CENTER - Component: 01 - Tag: 0918

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

Findings include:

1. Document review on January 7, 2026, at 9:00 a.m., revealed the facility could not produce the following reports:

a. 3-year, 4-hour load test.
b. Annual Fuel Quality.

Exit Interview with the Administrator and Maintenance Director on January 7, 2026, at 11:00 a.m., confirmed the missing documentation.

Plan of Correction - To be completed: 02/20/2026

Grand View Surgery Center was unable to provide the 3-year 4-hour load test at the time of the survey. This test was completed on 2/16/23. The report has since been obtained and filed in the Life Safety binder. In addition, we could not provide an annual fuel quality report. Penn Power obtained a fuel sample on 1/27/26. Moving forward, the St. Luke's Grand View facility manager has implemented a documentation system to ensure all load bank testing and fuel samples documentation are completed and immediately accessible. St. Luke's Grand View facility engineering will also perform routine environmental rounds to ensure continued compliance. This information will also be reviewed at the quarterly Safety Committee meeting.

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