Pennsylvania Department of Health
LEO R. MCCAFFERTY M.D. SURGICAL 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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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 15, 2024, 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 Fire Drills:

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.14.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform 1 of 4 required fire drills.

Findings include:

1. Review of documentation on October 15, 2024, at 8:30 a.m., revealed the facility lacked documentation for a fire drill performed in the second quarter.

Interview with the Facility Administrator and Maintenance Director on October 15, 2024, at 8:30 a.m., confirmed the facility lacked documentation for the drill between April and June in 2024.

Plan of Correction - To be completed: 10/15/2024

In reference to #0712, on October 15, 2024 the Leo R McCafferty MD Surgical Center LLC Facility Director of Nursing emailed the Safety director at UPMC Shadyside to inform him that fire drills must occur at random times and days each quarter. I reinforced that missing a fire drill can not occur again.

In an effort to ensure this does not happen again, the Director of Nursing for the Leo R McCafferty MD Surgical Center LLC Facility will monitor the completion of the fire drills on a quarterly basis; to help monitor this, the Director of Nursing, as of October 22, 2024, has set electronic reminders for roughly one month prior to the end of each quarter; if the drill has not been completed by the time of this reminder, the Director of Nursing will reach out to the safety director at UPMC to conduct and complete the required quarterly fire drill.

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