Pennsylvania Department of Health
SHADYSIDE SURGI-CENTER, INC.
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 29 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.


SHADYSIDE SURGI-CENTER, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
This report is the result of an unannounced revisit survey conducted on March 12, 2024 following a State Licensure survey completed on August 01, 2023, at Shadyside Surgi-Center, Inc. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.

Plan of Correction:

567.43 LICENSURE Ventilation System:

The ventilation system shall be inspected and maintained in accordance with the written maintenance schedule to ensure that a properly conditioned air supply meeting minimum filtration, humidity and temperature requirements is provided in critical areas such as the surgical and recovery suites under
Chapter 571 (relating to construction standards).

Observations:

Based on a review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure the ventilation system was inspected and maintained in accordance with a written maintenance schedule.

Findings include:

On March 12, 2024 a review of the facility, "Infection Control Plan," revised date, October, 2023, revealed, "iii. Preparation and Maintenance of Operating Room Environment: 1. OR ventilation must include a minimum of (15) air changes per hour, of which at least (3) should be fresh air...All air, recirculated or fresh, shall be filtered (at least 90% efficiency) before it enters the OR. The surgical suite must be under positive pressure relative to the surrounding area... Air exchanges will be measured when there is any structural change to the ventilation system or Surgi-Center rooms or a new infection trend is identified by the Infection Control Committee."

On March 14, 2024 at 12:44 PM, a written maintenance schedule was requested from the facility. EMP2 relayed that there is not a written maintenance schedule for obtaining a measurement of the air exchanges in the surgery center.

Plan of Correction - To be completed: 03/31/2024

The Infection Control Plan will be updated to include a written maintenance schedule with a specific time component to ensure that a properly conditioned air supply meets minimum requirements for filtration, humidity and temperature. The facility director will ensure compliance with the maintenance schedule and this will be reviewed by the Infection Control Committee at all meetings to ensure that this deficiency does not recur. This policy update will be implemented by March 31, 2024.

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