Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on March 24, 2026, at Mahoning Valley Ambulatory Surgery Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 416.54.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID# 12821500
Component 01
Main Building
Based on a Recertification/Relicensure Survey completed on March 24, 2026, it was determined that Mahoning Valley Ambulatory 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 42 CFR 416.44(b).
This is a one story, Type V (000), unprotected, wood frame building, that is nonsprinklered.
Plan of Correction:
NFPA 101 STANDARD
Fire Drills
Name - MAIN BUILDING 01 Component - 01
Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
21.7.1.4 through 21.7.1.7
Observations:
Based on documentation review and interview, it was determined the facility failed to maintain fire drills, affecting one of one floor.
Findings include:
1. Observation on March 24, 2026, at 10:40 a.m., revealed four of four required fire drills were conducted within one day of one another, with respect to day of the affected months.
Exit interview with the Facility Administrator on March 24, 2026, at 11:25 a.m., confirmed the fire drill deficiency.
Plan of Correction:1.The Mahoning Valley ASC will track the dates and times of the fire drills for each quarter. We will ensure that fire drills are done during different weeks, date, days, and times with different scenarios for proper training and preparedness.
2. We will begin this process with our second quarter drill of 2026.
3. We will create a chart in excel that will track what week, date, day, and time the drill is performed.
4. The fire drill monitoring process will be reported by the administrator at the quarterly Patient Safety meeting to ensure compliance.
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