Pennsylvania Department of Health
ALLEGHENY REPRODUCTIVE HEALTH CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 41 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.


ALLEGHENY REPRODUCTIVE HEALTH CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced Special Monitoring survey conducted on April 15, 2024, at Allegheny Reproductive Health Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.

Plan of Correction:

551.22 (3)(i) LICENSURE Criteria for Performance on Pediatirc Patient:

551.22. Criteria for Performance of Ambulatory Surgery on Pediatric Patients

In addition to the criteria set forth at 551.21 (relating to criteria for ambulatory surgery), the following criteria shall apply to the performance of ambulatory surgery on children under 18 years of age.
(3) Surgical procedures on persons older than 6 months and younger than 18 years of age shall be performed only under the following conditions:
(i) Anesthesia services shall be provided by an anesthesiologist who is a graduate of an anesthesiology residency program accredited by the accreditation council for graduate medical education or its equivalent, or by a certified registered nurse anesthetist trained in pediatric anesthesia, either of whom shall have documented demonstrated historical and conditions competence in the care of such patients.

Observations:

Based on review of facility documents, medical record review (MR), and staff interview (EMP), it was determined the facility failed to ensure that anesthesia services for pediatric patients were provided by a qualified practitioner for two of 20 medical records reviewed (MR9 and MR16).

Findings include:

A review, on April 15, 2024, at 11:15 A.M., of the facility's medical staff bylaws, date October 2023, revealed ..." ... 4. ANESTHESIA SERVICES 4.1. Principle. (a) Anesthesia services provided in the facility are limited to those techniques that are approved by the governing body upon the recommendation of qualified medical staff. They shall be limited to those techniques appropriate to the assigned classification per Abortion Facility license. ... 4.2. Administration of anesthesia. (a) Anesthesia shall be administered by a certified registered nurse anesthetist (CRNA) or Medical Doctor.(b) Monitored anesthesia care (MAC) shall be administered by a certified registered nurse anesthetist. (c) Light/moderate/monitored anesthesia sedation shall be administered by a certified registered nurse anesthetist (CRNA) or Medical Doctor. ... ".

A review of MR9 on April 15, 2024, revealed that the pediatric patient received 50 mg of Ketamine Intramuscular (IM) administered by registered nurse (RN) EMP2, on April 9, 2024.

A review of MR16 on April 15, 2024, revealed that the pediatric patient received 50 mg of Ketamine IM administered by RN EMP3, on January 6, 2024.

During an interview on April 15, 2024 at approximately 12:45 PM, EMP1 confirmed the above findings.

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

555.31 (a) LICENSURE ANESTHESIA SERVICES - Principle:

Anesthesia Services

555.31 Principle
(a) Anesthesia services provided in the facility are limited to those techniques that are approved by the governing body upon recommendation of qualified medical staff. They shall be limited to those techniques appropriate to the assigned classification per ASF licence.

Observations:

Based on review of facility documents, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to ensure only techniques approved for a Class B Surgery Center were provide to patients for two of 20 medical records reviewed (MR9 and MR16).

Findings include:

A review, on April 15, 2024, at 11:15 A.M., of the facility's medical staff bylaws, date October 2023, revealed ..." ... 4. ANESTHESIA SERVICES 4.1. Principle. (a) Anesthesia services provided in the facility are limited to those techniques that are approved by the governing body upon the recommendation of qualified medical staff. They shall be limited to those techniques appropriate to the assigned classification per Abortion Facility license. ... 4.2. Administration of anesthesia. (a) Anesthesia shall be administered by a certified registered nurse anesthetist (CRNA) or Medical Doctor.(b) Monitored anesthesia care (MAC) shall be administered by a certified registered nurse anesthetist. (c) Light/moderate/monitored anesthesia sedation shall be administered by a certified registered nurse anesthetist (CRNA) or Medical Doctor. ... ".

A review of MR9 on April 15, 2024, revealed that the pediatric patient received a general anesthetic of 50 mg of Ketamine Intramuscular (IM) administered by EMP2, on April 9, 2024.

A review of MR16 on April 15, 2024, revealed that the pediatric patient received a general anesthetic of 50 mg of Ketamine IM that was administered by EMP3, on January 6, 2024.

During an interview on April 15, 2024 at approximately 12:45 PM, EMP1 confirmed the above findings.

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

555.32 (a) LICENSURE Administration of Anesthesia:

Anesthesia Services

555.32 Administration of anesthesia

(a) Anesthetics shall be administered by anesthesiologists and certified registered nurse anesthetist and dentist anesthetists as defined in 551.3 (relating to definitions).

Observations:

Based on review of facility documents, medical (MR), and staff interview (EMP), it was determined the facility failed to ensure that anesthesia was administered by an Anesthesiologist or Certified Registered Nurse Anesthetist who is trained and qualified for two of 20 medical records reviewed (MR9 and MR16).

Findings include:

A review, on April 15, 2024, at 11:15 A.M., of the facility's medical staff bylaws, date October 2023, revealed ..." ... 4. ANESTHESIA SERVICES 4.1. Principle. (a) Anesthesia services provided in the facility are limited to those techniques that are approved by the governing body upon the recommendation of qualified medical staff. They shall be limited to those techniques appropriate to the assigned classification per Abortion Facility license. ... 4.2. Administration of anesthesia. (a) Anesthesia shall be administered by a certified registered nurse anesthetist (CRNA) or Medical Doctor.(b) Monitored anesthesia care (MAC) shall be administered by a certified registered nurse anesthetist. (c) Light/moderate/monitored anesthesia sedation shall be administered by a certified registered nurse anesthetist (CRNA) or Medical Doctor. ... ".

A review of MR9 on April 15, 2024, revealed that the pediatric patient received 50 mg of Ketamine Intramuscular (IM) administered by Registered Nurse (RN) EMP2, on April 9, 2024.

A review of MR16 on April 15, 2024, revealed that the pediatric patient received 50 mg of Ketamine IM administered by a Registered Nurse EMP3, on January 6, 2024.

During an interview on April 15, 2024 at approximately 12:45 PM, EMP1 confirmed the above findings.

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement