Pennsylvania Department of Health
FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER, LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: 00 - Tag: 0000
Based on an Emergency Preparedness Survey completed on May 22, 2025, it was determined that Fertility Partners of Pennsylvania Surgery Center, Llc was not in compliance with the requirements of 42 CFR 416.54.

Plan of Correction:

403.748(c), 416.54(c), 418.113(c), 441.184(c), 482.15(c), 483.475(c), 483.73(c), 484.102(c), 485.542(c), 485.625(c), 485.68(c), 485.727(c), 485.920(c), 486.360(c), 491.12(c), 494.62(c) STANDARD Development of Communication Plan:

§403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c).

(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities].

Observations:
Name: - Component: 00 - Tag: 0029 Based on document review and interview, it was determined the facility failed to maintain an emergency communications plan as part of the emergency preparedness plan, affecting the entire component. Findings include: Review of documentation on May 22, 2025, at 9:25 AM, revealed the facility lacked a communications plan as part of the emergency preparedness plan.Interview with the Administrator on May 22, 2025, at 9:25 AM, confirmed the lack of a communications plan.

Plan of Correction - To be completed: 06/23/2025

Upon review of the surgery center's disaster preparedness manual, it was identified that no emergency communication plan was created in the emergency preparedness binder. The Safety Officer and the Clinical Director of the surgery center will compose a communication plan that is to be approved by the governing body by June 23rd, 2025. The Safety officer and the Clinical Director will conduct staff in-service to inform the staff members about the emergency communication plan. Education will include where to find the plan, how to use it in the event of an emergency, and who/how to contact the appropriate personnel. The Safety Officer and Clinical Director will ensure compliance by reviewing and updating the communication plan on a biannual basis to make sure it is up to date with the correct contact information.

Initial comments:Name: FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER - Component: 10 - Tag: 0000

Facility ID #24571501

Component 01

Fertility Partners of Pennsylvania Surgery Center, Llc
Based on a Recertification/Relicensure Survey completed on May 22, 2025, it was determined that Fertility Partners of Pennsylvania Surgery Center, Llc was not in compliance with the following requirements of the Life Safety Code for a new 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 three-story, Type II (000), unprotected noncombustible structure, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
Hazardous areas must meet one of the following:
*Contain 1 hour rated enclosure when non-sprinklered
*Sprinkler protected with smoke resistive separation
*Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7

Observations:
Name: FERTILITY PARTNERS OF PENNSYLVANIA SURGERY CENTER - Component: 10 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain the positive latching of doors to hazardous area enclosures, affecting the entire component. Findings include: Observation on May 22, 2025, at 10:20 AM, revealed the clean side door to the Dirty/Soiled Room was equipped with an electronic strike plate, which was programmed to only provide positive latching during the hours the facility is closed.Interview with the Administrator on May 22, 2025, at 10:20 AM, confirmed the door to the hazardous area did not positively latch within the door frame.

Plan of Correction - To be completed: 05/23/2025

Communicated with Datawatch Systems, Inc. That there must be positive latching of door #1017 24/7. On May 23rd, 2025, the electronic strike plate was programmed to provide positive latching 24/7. The Safety Officer and the Clinical Director of the surgery center will begin a random audit on June 4th, 2025 of 10 instances per month to ensure the Dirty/Soiled Room door has a positive latch. The audit will continue until 100% compliance is met for three consecutive months. Results of the audit will be presented by the Safety Officer and the Clinical director of the surgery center at the quarterly QAPI meeting.

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