Pennsylvania Department of Health
POCONO AMBULATORY SURGERY CENTER, LIMITED
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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POCONO AMBULATORY SURGERY CENTER, LIMITED - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced offsite special monitoring survey completed on March 15, 2024, at Pocono Ambulatory Surgery Center. 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:

51.4 (b) LICENSURE Change in Ownership/Management:

51.4. Change in ownership; change in management.

(b) A health care facility shall notify the Department in writing at least 30 days prior to a change in
ownership or a change in the form of ownership or name of the facility. A change in ownership shall mean any transfer of the controlling interest in a health care facility.

Observations:

Based on review of facility documents, staff interview (EMP), and email correspondence, it was determined the Pocono Ambulatory Surgery Center failed to provide notification to the Department for a change of ownership.

Findings include:

Review on March 13, 2024, of a facility letter sent to the Department, dated March 12, 2024 revealed "Pocono Ambulatory Surgery Center is writing this to alert you of changes to the ownership percentage of our General Partner, LVH-P from 65.75% to 70.75%....."

Review on March 13, 2024, of the Department's email correspondence from EMP1 dated March 12, 2024, revealed the Pocono Ambulatory Surgery Center underwent a Change of Ownership in 2023.

Interview on March 15, 2024, at 1230 with EMP1 confirmed the facility sent a Change of Ownership letter to the Department on March 12, 2024. EMP1 was unable to confirm the effective date of the change of ownership. EMP1 confirmed the Department was not sent notification at least 30 days prior to the Change of Ownership.

Plan of Correction - To be completed: 04/12/2024

A formal notification letter will be submitted to the Dept. of Health advising of the Pocono Ambulatory Surgery Center's recent ownership change.

Any future change in ownership will be communicated to the Dept. of Health a minimum of 30 days prior to the anticipated change.

PA Code Chapter 51 notification requirements were reviewed by the PASC Director and the LVHN Regulatory and Legal Leaders.

Plan of correction completed by April 12, 2024. PASC Director is responsible for implementation of this plan.

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