Pennsylvania Department of Health
LEO R. MCCAFFERTY M.D. SURGICAL CENTER, LLC
Building 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 26 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.


LEO R. MCCAFFERTY M.D. SURGICAL CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 50261501
Component 01
Shadyside Place Building

Based on a Relicensure Survey completed on October 19, 2023, it was determined that Leo R. McCafferty, M.D., Plastic Surgery was not in compliance with the following requirements of the Life Safety Code for an existing 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 five-story, Type IV (2HH), heavy timber building, with a basement, that is fully sprinklered.

The ASC is on the fifth floor.

Plan of Correction:

28 Pa. Code § 569.2 STANDARD Emergency Lighting:

Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0291

Based on document review and interview, it was determined the facility failed to maintain emergency lighting in one instance, affecting the entire facility.

Findings include:

1. Documentation review on October 19, 2023, at 8:45 a.m., revealed the facility lacked documentation for an annual 90-minute test for the emergency lights.

Interview with the Facility Administrator and Maintenance Director on October 19, 2023, at 8:45 a.m., confirmed the facility lacked documentation for the annual 90-minute test for the emergency lights.

Plan of Correction - To be completed: 10/20/2023

Plan of Correction:
A meeting was held 10/19/2023 with the clinical director and the director of engineering and maintenance for UPMC Shadyside to discuss and correct the plan of correction regarding observation #0291.
UPMC engineering and maintenance found the date entered in the system was incorrect therefore, it did not generate the work order to complete the 90 minute test on the emergency lights in the operating room.

UPMC engineering and maintenance contacted dispatch on 10/19/2023 and the dates in the system were corrected. The report will print when the testing is due next October of 2024.

The 90 minute test on the operating room Emergency lights was completed 10/20/2023. A copy of the test will be maintained by UPMC engineering and maintenance and be available upon request.

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