Pennsylvania Department of Health
SUSQUEHANNA VALLEY SURGERY CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SUSQUEHANNA VALLEY SURGERY CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a full State Licensure survey initiated on February 19, 2026, and concluded on February 27, 2026, at Susquehanna Valley Surgery Center. It was determined 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:

551.22 (2) LICENSURE Criteria for performance Of Pediatric 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.
(2) The medical record shall include documentation that the child's primary care provider was notified by the surgeon in advance of the performance of a procedure in an ambulatory surgical facility and that an opinion was sought form the primary care provider regarding the appropriateness of the use of the facility for the proposed procedure. When such an opinion from the child's primary care provider is not obtainable, the medical record shall include documentation which explains why such an opinion could not be obtained.

Observations:

Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to include documentation that the child's primary care provider (PCP) was notified by the surgeon in advance of the procedure performed and that an opinion was sought from the PCP regarding the appropriateness of the use of the facility for the proposed procedure in one of two pediatric medical records reviewed (MR5).

Findings include:

Request for facility Pediatric Authorization Policy. None provided.

Review of MR5 on February 19, 2026, revealed on September 30, 2025, a Tonsillectomy, Adenoidectomy was performed on MR5. MR5 lacked documented evidence that the surgeon notified the PCP or obtained the opinion of the PCP regarding the appropriateness of the use of the facility for the procedure performed. Further review revealed no documentation which explained why notification or an opinion could not be obtained.

Interview with EMP1 on February 19, 2026, EMP1 confirmed the information above is complete and accurate.

Plan of Correction - To be completed: 05/12/2026

Education was provided to staff during a meeting, held on March 2, 2026. Meeting minutes were updated to include the official DOH report and dispersed to staff via email on March 11, 2026 with a read receipt. Department leadership, or designee, will audit 10 or actual number of pediatric charts every month for compliance with having either confirmed clearance or verification that at least one attempt was made to obtain the authorization. Staff that are non-compliant will receive additional education and coaching. Audits will continue until 100% compliance is achieved for three consecutive months. Results of audits will be reviewed during the ASF Quality Meeting.

555.11 (a) LICENSURE MEDICAL ORDERS - Written:

555.11 Medical orders
Written orders

(a) Medication or treatment shall be administered by authorized persons to administer drugs and medications only upon written and signed orders of a practitioner acting within the scope
of the practitioner's license.

Observations:

Based on review of facility documents, medical records (MR), and staff interview (EMP) it has been determined the facility failed to ensure written orders were signed/authenticated by a practitioner according to policy in three of ten medical records reviewed (MR4, MR6, MR7).

Findings include:

On February 19, 2026, review of facility document "Medical Staff Bylaws, Policies and Rules and Regulations of UPMC Medical Staff Rules and Regulations" with an effective date of May 6, 2025, revealed "Article V Medical Orders 5. E. Standing Orders, Order Sets, and Protocols (1) The Medical Executive Committee (MEC) allows the use of pre-printed and electronic standing orders, order sets, and protocols for patient orders when the following criteria are met: (a) the MEC and the Hospital's nursing and pharmacy departments must review and approve any standing orders, order sets, and protocols (collectively, 'standing orders') that permit treatment to be initiated by an individual (for example, a nurse) without a prior specific order from the Attending Physician; and (b) all standing orders must identify well-defined clinical scenarios for when the order is to be used. (2) The MEC will adopt the findings of the UPMC Electronic Practice Guidelines ("EPG") and/or the UPMC System Pharmacy & Therapeutics Committee, as applicable, confirming that all approved standing orders and protocols are consistent with nationally recognized and evidence-based guidelines. The MEC will also ensure that such standing orders and protocols are reviewed at least annually. (3) If the use of a standing order has been approved by the MEC, treatment may be initiated (i) by a nurse or other authorized individual acting within their scope of practice who activates the order; or (ii) when a nurse enters documentation into the medical record that triggers the standing order. (4) When used, standing orders must be dated, timed, and authenticated promptly in the patient's medical record by the individual who activates the order or by another responsible practitioner. (5) The Responsible Practitioner must authenticate the initiation of each standing order after the fact, with the exception of those for influenza and pneumococcal vaccines, which may be administered per Hospital policy after an assessment for contraindications."

Reveiw of MR4 on February 19, 2026, revealed on October 17, 2025, at 1157 EMP2 entered an order for BUPivacaine PF 0.25% injection; it was administered by EMP3 at 1157. The order entered by EMP2 was not authenticated by a Practitioner. Further review of MR4 on February 19, 2026, revealed on October 17, 2025, at 1052 EMP4 entered an order for Peripheral IV access; it was performed by EMP5 at 1135, lactated ringer's infusion; 20ml performed by EMP5 at 1137. The orders entered by EMP4 on October 17, 2025, at 1052 were cosigned EMP6 on October 20, 2025, at 0635.

Review of MR6 on February 19, 2026, revealed on October 28, 2025, at 1042 EMP7 entered an order for BUPivacaine PF 0.25% injection; it was administered by EMP8 at 1042, lidocaine PF (Xylocaine) 1% injection; administered by EMP8 at 1042; sodium chloride 0.9% irrigation solution; administered by EMP8 at 1043. The orders entered by EMP7 were not authenticated by a Practitioner.
Review of MR7 on February 19, 2026, revealed on November 25, 2025, at 1556 EMP4 entered an order for lidocaine PF (Xylocaine) 1% injection: administered by EMP9 at 1556. The order entered by EMP7 was not authenticated by a Practitioner.

Interview with EMP1 on February 19, 2026, EMP1 confirmed all above information is accurate and does not comply with facility policy.

Plan of Correction - To be completed: 05/12/2026

ASF leadership, information technology staff, and regulatory representatives met to review the current Epic workflow. An Epic update is in development to support workflow that ensures that all orders are authenticated. All providers and RN staff will be educated by 5/12/2026 on the new Bridges workflow to validate understanding of order authentication requirements.
Leadership or designee will perform 20 chart audits per month to evaluate compliance with cosigning all protocol orders. Audits will be performed monthly until 100% compliance is achieved for 3 consecutive months.
Results of audits will be shared during the quarterly ASF Quality Meeting for the duration of the action plan.

555.22 (b) LICENSURE Surgical Services - Preoperative Care:

555.22 Pre-operative Care

(b) A written statement indicating informed consent, obtained by the practitioner, and signed by the patient, or responsible person, for the performance of the specific procedures shall be procured and made part of patient's clinical record. It shall contain a statement which evidences the appropriateness of the proposed surgery, as well as any alternative treatments discussed with the patient. It shall also identify any practitioner who shall participate in the surgery.

Observations:

Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to identify all practitioners who participated in the procedure on four of ten medical records reviewed (MR1, MR3, MR4, MR7).

Findings include:

On February 24, 2026, review of facility policy "Patient Informed Consent" dated July 1, 2025, revealed "Policy/Purpose/Scope- It is the policy of UPMC to recognize an individual patient's right to be informed of and consent to procedures performed and treatments provided at UPMC facilities or at facilities where UPMC personnel may render care, including via telemedicine, in accordance with applicable law. ... 2. Recommended Communication Tools and Techniques b. Procedure-Specific Consent Forms. Procedure specific consent forms are available on Infonet under the clinical tools tab. It is recommended that these forms are used for consenting the patient as they are comprehensive and address all medical and legal concerns regarding the procedure."

Review of MR1 on February 19, 2026, revealed on September 29, 2025, EMP10 performed a Closed Reduction of Percutaneous Pinning of Right Index Distal Phalanx (Right: Index Finger) with the assistance of EMP11. Informed Consent form for MR1 does not identify EMP11 as a participant in the procedure completed.

Review of MR3 on February 19, 2026, revealed on October 7, 2025, EMP12 performed a Right shoulder diagnostic arthroscopy, arthroscopic rotator cuff repair, biceps tenodesis, examination under anesthesia, subacromial decompression, extensive debridement (Right)
with the assistance of EMP13. Informed Consent form for MR3 does not identify EMP13 as a participant in the procedure completed

Review of MR4 on February 19, 2026, revealed on October 17, 2025, EMP3 performed an Excision of Perineal Mass with the assistance of EMP14. Informed Consent form for MR4 does not identify EMP14 as a participant in the procedure completed.

Review of MR7 on February 19, 2026, revealed on November 25, 2025, EMP9 performed an Excision of osteophyte and sesamoid at right thumb interphalangeal joint and right carpal tunnel release with the assistance of EMP15. The "Informed Consent" form for MR7 does not identify EMP15 as a participant in the procedure completed.

Interview with EMP1 on February 19, 2026, EMP1 confirmed the above information is accurate and complete.

Plan of Correction - To be completed: 05/12/2026

Consent forms will be revised to include identification of any practitioners (licensed physician, dentist or podiatrist) other than the main performing practitioner will be included in intraoperative documentation.
All staff will be educated by 5/12/2026 on the requirements to add all practitioners to the informed consent.
Leadership or designee will perform 20 or actual amount of chart audits per month to evaluate compliance with proper identification of all practitioners on the consent. Audits will be performed monthly until 100% compliance is achieved for 3 consecutive months.
Results of audits will be shared during the quarterly ASF Quality Meeting for the duration of the action plan.

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 review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure the Procedure Rooms/Operating Rooms, PACU and Pre-OP rooms met the humidity level requirements per policy.
Findings include:

On February 19, 2026, review of facility policy "Humidity and Temperature Control" with original date of January 18, 2024, revealed "POLICY It is the policy of UPMC Pinnacle hospitals to maintain temperature and humidity within defined parameters in the critical areas to ensure a safe environment and reduce infection control concerns. Rooms that are considered critical, like those where invasive procedures are performed or where sterile items are stored, are to be in constant compliance when being used for their intended purpose. II. PURPOSE The purpose of this policy is to provide guidance regarding the management of humidity and temperature controls in critical areas. Temperature and humidity controls shall be set according to the "Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Facilities "as outlined in the Guidelines for Design and Construction of Hospital and Health Care Facilities. PROCEDURE 1. Humidity controls shall be set to maintain relative humidity ranges per FGI/ASHRE guidelines in the critical areas in which invasive procedures are performed or where sterile items are stored. 2. Temperature controls for critical areas shall be set at the level designated by the "Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Facilities " guidelines outlined in the Guidelines for Design and Construction of Hospital and Health Care Facilities. a) Surgeons or surgical procedures may require room temperatures, ventilation rates, humidity ranges, and/or air distribution methods that exceed the minimum indicated ranges. 3. The Facilities Maintenance Department performs computerized checks of the temperature and humidity in critical areas daily. The report is made available to the Director of those critical areas or their designee for review. 4. If temperature or humidity go out-of-range and cannot be rectified: a) The Manager of Facilities Maintenance or their designee will notify the Director of those critical areas or their designee. b) The Facilities and Engineering staff member will generate a computerized work order, noting the corrective work performed."

On February 19, 2025, review of the "2008 ANSI/ASHERAE TABLE 7-1 Design Parameters" which is referenced in the facility poloicy revealed "Function of Space - Classes B and C operating rooms ... Recovery room ... Relative Humidity (k), %, 30-60"

On February 19, 2026, review of facility temperature and humidity log manually collected by facility staff for the Gastrointestinal (GI) Procedure room revealed:

On July 2, 2026, the humidity in the procedure room was 74%, and two procedures were performed that day.
On July 8, 2026, the humidity was 69%, and six procedures were performed that day.
On July 10, 2026, the humidity was 71%, and six procedures were performed that day.
On July 11, 2026, the humidity was 72%, and three procedures were performed that day.
On July 16, 2026, the humidity was 77%, and one procedure was performed that day.
On July 23, 2026, the humidity was 71%, and seven procedures were performed that day.
Request for work order sent to Maintenance team for data above. None provided.
Request for temperature and humidity monitoring of GI procedure room the months of August to December 15, 2025. None provided.
Request for temperature and humidity monitoring of Recovery areas for the months of August to December 15, 2025. None provided.
Review of facility computerized "Temperature/Humidity Log" revealed: Operating Room one (1) humidity reading results to be below 30% November 1,2, 4-7, 10,11,16-18, 2025, and November 23, 24, 27-30, 2025; December 1-17, 20, 21 2025, with readings dropping as low as 12%.

Review of facility computerized "Temperature/Humidity Log" revealed: Operating Room two (2) humidity reading results to be below 30% November 1, 4-7, 10,11,18, 2025, and November 27-30, 2025; December 1, 3-17, 20, 21,2025, with readings dropping as low as 16%.

Review of facility computerized "Temperature/Humidity Log" revealed: Operating Room three (3) humidity reading results to be below 30% November 1-7, 10,11,14-25, 2025, and November 27-30, 2025; December 1-17, 20, 21 2025, with readings dropping as low as 4%.

Review of facility computerized "Temperature/Humidity Log" revealed: Operating Room five (5) humidity reading results to be below 30% November 11,18, 27-29, 2025; December 1,3-9, 11-17, 20,21, 2025, with readings dropping as low as 10%.

Request for safety checks performed on dates humidity was out of range, physician notation to proceed with procedures while humidity levels were out of range none was provided.

Interview with EMP1 on February 19, 2026, EMP1 confirmed procedures with the use of electrocautery were performed on the above dates noted where humidity levels were below range. EMP1 also confirmed the issue has been in effect for the year 2025 and the facility is seeking to replace the HVAC system.

Plan of Correction - To be completed: 05/12/2026

The organization has approved the design and replacement of the HVAC system and additional electronic building automated system at the ASF. In the meantime, to address any out-of-range humidity readings, the following process is followed:
Alert parameters are set in the electronic building automated system to ensure prompt direct notification of the facilities department staff members of any out-of-range humidity conditions.
A daily humidity report is generated and sent electronically to key stakeholders.
Using the algorithm contained within the policy, Humidity and Temperature Control, the appropriate staff members will take the defined action steps in response to out-of-range values. Any corrective actions taken by Facilities in response to the alerts will be documented in the electronic work order system.
If the relative humidity remains out of compliance, the Medical Director or designee will review the values and make the determination if it is safe to proceed with cases. This review will be documented on an attestation form.
The ASF Administrator or designee will audit compliance with following the relative humidity out-of-range action steps.
Audits will be reviewed during the ASF Quality meetings.

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