Initial Comments:
This report is the result of a full State Licensure survey conducted onsite on March 11, 2026 at The Center for Specialized Surgery, L.P. 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:
553.3 (1) LICENSURE
Governing Body Responsibilities
Name - Component - 00
553.3
Governing Body responsibilities include:
(1) Conforming to all applicable Federal, State, and local laws.
Observations:
Based on review of facility policy, facility documents and interview with staff (EMP), it was determined that the facility failed to conform to applicable State Laws.
The facility was not in compliance with the following State law:
Medical care Availablity and Reduction of Error (MCARE) Act of March 20, 2002, P.L. 154, No. 13. Section 310. (a) (2). Patient safety committee. Composition. The committee shall meet at least quarterly.
Based on review of facility policy, facility documents and interview with staff (EMP), it was determined that the facility failed to ensure that a separate and distinct patient safety committee held quarterly meetings.
Findings include:
Review on March 11, 2026 of the facility's "Patient Safety Program" reviewed November 2025, revealed..."The patient safety committee will promote the health and safety of patients and staff, review and evaluate the quality of safety measures used in the organization to assist with implementation of the safety activities. This patient safety committee can be the same members as the quality improvement/performance improvement committee and employee safety committee, reviewing all areas of performance, safe work environment, and safe patient care processes." Further review of this document revealed no mention of frequency of patient safety committee meetings.
Review on March 11, 2026, of the facility's "Medical Executive Committee Meeting Minutes", dated April 14, 2025, revealed no documented evidence that a separate and distinct patient safety meeting was held for the first quarter of 2025.
Review on March 11, 2026, of the facility's "Medical Advisory Committee" Meeting Minutes, dated July 7, 2025, revealed no documented evidence that a separate and distinct patient safety meeting was held for the second quarter of 2025.
Review on March 11, 2026, of the facility's "Medical Advisory Committee" Meeting Minutes, dated October 20, 2025, revealed no documented evidence that a separate and distinct patient safety meeting was held for the third quarter of 2025.
Review on March 11, 2026, of the facility's "Medical Advisory Committee" Meeting Minutes, dated January 12, 2026, revealed no documented evidence that a separate and distinct patient safety meeting was held for the fourth quarter of 2025.
Interview on March 11, 2026 12:55 PM, with EMP2 confirmed the Medical Advisory Committee meeting, formerly known as the Medical Executive Committee meeting functioned as the facility's patient safety committee meetings. Further interview confirmed that no separate and distinct patient safety meeting was held in April 2025, July 2025, October 2025, and January 2026.
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The Center for Specialized Surgery, L.P. was not in compliance with the following State law:
Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act "40 PS. 1303.310 Patient safety committee. (a) Composition... (2) An ambulatory surgical facility's... patient safety committee shall be composed of the medical facility's patient safety officer and at least one health care worker of the medical facility and one resident of the community served by the ambulatory surgical facility...who is not an agent, employee or contractor of the ambulatory surgical facility..."
This is not met as evidenced by:
Based on a review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure that a resident of the community served as member on the patient safety committee for four out of four meetings from March 2025 through January 2026.
Findings include:
Review on March 11, 2026, of the facility's "Patient Safety Program", Revised November 2025, revealed "This patient safety committee can be the same members as the quality improvement/performance improvement committee and employee safety committee" The document did not mention a community member.
Review on March 11, 2026, of the facility's "Medical Executive Committee Meeting Minutes", dated April 14, 2025, revealed no documented evidence that a resident of the community was in attendance at the April 2025 meeting.
Review on March 11, 2026, of the facility's "Medical Advisory Committee" Meeting Minutes, dated July 7, 2025, revealed no documented evidence that a resident of the community was in attendance at the July 2025 meeting.
Review on March 11, 2026, of the facility's "Medical Advisory Committee" Meeting Minutes, dated October 20, 2025, revealed no documented evidence that a resident of the community was in attendance at the October 2025 meeting.
Review on March 11, 2026, of the facility's "Medical Advisory Committee" Meeting Minutes, dated January 12, 2026, revealed no documented evidence that a resident of the community was in attendance at the January 2026 meeting.
Interview on March 11, 2026 12:55 PM, with EMP2 confirmed the Medical Advisory Committee meeting, formerly known as the Medical Executive Committee meeting functioned as the facility ' s patient safety committee meetings. Further interview confirmed that a community member representative was not present at these meetings in April 2025, July 2025, October 2025, and January 2026.
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The Center for Specialized Surgery, L.P. was not in compliance with the following State law:
"Act 52 of 2007, Medical Care Availability and Reduction of Error (MCARE) Act Chapter 4. Health Care-Associated Infections 40 P.S.1303.403. Infection control plan (a) Development and Compliance. - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include: (1) A multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility ... (ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility."
This is not met as evidenced by:
Based on a review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure that a resident of the community served as member on the Infection Control Committee Meeting for four out of four meetings from March 2025 through January 2026.
Findings include:
Review on March 11, 2026, of the facility's "Annual 2026 Infection Prevention Plan", Revised January 2026, revealed "The Infection Prevention Committee ...will be comprised of the following members: 1. The Medical Director oversight recommended. 2. Other members may include but are not limited to: Infection Preventionist, Medical staff, quality leader, and Executive leadership, Nursing, Sterile Processing, Safety/Risk Management, Employee Health, and Clinic Leadership." The document did not mention a community member.
Review on March 11, 2026, of the facility's "Infection Control" meeting minutes dated April 14, 2025, revealed no documented evidence that a resident of the community was in attendance at the April 2025 meeting.
Review on March 11, 2026, of the facility's "Infection Control" Meeting Minutes, dated July 7, 2025, revealed no documented evidence that a resident of the community was in attendance at the July 2025 meeting.
Review on March 11, 2026, of the facility's "Infection Control" Meeting Minutes, dated October 20, 2025, revealed no documented evidence that a resident of the community was in attendance at the October 2025 meeting.
Review on March 11, 2026, of the facility's "Infection Control" Meeting Minutes, dated January 12, 2026, revealed no documented evidence that a resident of the community was in attendance at the January 2026 meeting.
Interview on March 11, 2026 12:55 PM, with EMP2 confirmed that a community member representative was not present at the Infection Control meetings in April 2025, July 2025, October 2025, and January 2026.
Plan of Correction:The Governing Board was made aware of survey finds via ad hoc meeting on March 24, 2026.
The Patient Safety Committee and Infection Control Committee membership requirements were reviewed with the governing board in the ad hoc findings review, and a plan of correction was approved below.
The Patient Safety Plan and the Infection Control Plan were amended and approved by the Governing Board to include the requirements of the committee to include a member of the community.
The community member was notified and reminded of the requirement to be in attendance of the quarterly Patient Safety meeting in person, via video conferencing or telephone, to which they committed to doing going forward.
The Governing Board approved the addition of a community member to be included in the Infection Control committee and approved the appointment of the nominated community member. This is documented in the Ad Hoc Meeting Minutes.
The community member is committed to membership in the Infection Control Committee and will consistently attend and participate in the infection control meetings going forward. The next quarterly meeting will be held on April 13, 2026. The community member's attendance will be documented on separate meeting minutes per Pennsylvania regulations. Quarterly audits will be completed by the Administrator to ensure that one hundred percent of compliance is achieved. The audit results will be shared with the Medical Advisory Committee and the Governing Board.
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The requirement for a community member to be present and involved in the separate, quarterly patient safety committee meeting will be upheld and documented in separate meeting minutes per Pennsylvania regulations. The next Patient Safety meeting will be held on April 13, 2026. Quarterly audits will be completed by the Administrator to ensure that one hundred percent of compliance is achieved. The audit results will be shared with the Medical Advisory Committee and the Governing Board during quarterly meetings.
If a community member is unable to consistently participate in the required separate quarterly meetings in person, by video conferencing or by phone, a replacement member will be approved by the Governing Board, and the replacement approval will be documented in meeting minutes.
The Administrator, as an active member of both committees, will be responsible for ensuring that a community member is an active part of and participates in the quarterly meetings held by the Patient Safety Committee and Infection Control Committee meetings. Any concerns of compliance with the requirements will be reported to the Medical Advisory Committee and Governing Board during quarterly meetings.
555.11 (a) LICENSURE
MEDICAL ORDERS - Written
Name - Component - 00
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 policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure medications or treatment were administered only upon a written and signed order of a practitioner for three of twelve medical records reviewed. (MR7, MR9, MR12)
Findings include:
Review on March 11, 2026 of Facility Policy "Medication Orders" revised October 2022 revealed "...1. Drug orders must be made by a doctor ...There should be five common elements present when a drug is ordered ...b. Right Drug c. Right Dose d. Right Route...3. All drug orders must be signed."
Review on March 11, 2026 of "Admission Protocol" revised September 2025 revealed "...8. Any pre-procedure preparations, such as pre-procedure medications, IV's and/or preps will be carried out according to the pre-procedure orders."
Review on March 11, 2026 of MR7 who received a tonsillectomy and adenoidectomy on May 7, 2025 revealed "Pre-Op Orders" with standing order to start IV, however, physician failed to specify dose, rate or type of IV fluids to administer. Further review of MR7 revealed "Post-Op Orders" with standing order "may resume all pre-op medications". Both order sections were signed with a date and time by a physician, and initialed with a date and time by RN. Further review of MR7 revealed "Post-Anesthesia Record", MR7 received 100 [no units of measurement included] of Normal Saline Solution (NSS) infused in Post Anesthesia Care Unit (PACU).
Review on March 11, 2026 of MR9 who received a right ear exam, right ear tube removal, and myringoplasty on May 7, 2025 revealed "Pre-Op Orders" with standing order to start IV, however, physician failed to specify dose, rate or type of IV fluids to administer. Further review of MR9 revealed "Post-Op Orders" with standing order "may resume all pre-op medications". Both order sections were signed with a date and time by a physician, and initialed with a date and time by RN. Further review of MR9's "Pre-Procedure Nursing Assessment" revealed 500 [no units of measurement included] infused of Normal Saline (NS), IV rate listed as "KVO [Keep Vein Open]". Further review of MR9's "Post-Anesthesia Record", MR9 received 100 [no units of measurement included] of NSS infused in PACU.
Review on March 11, 2026 of MR12 who received a tonsillectomy and adenoidectomy on October 1, 2025 revealed "Pre-Op Orders" with standing order to start IV, however, physician failed to specify dose, rate or type of IV fluids to administer. Further review of MR12 revealed "Post-Op Orders" with standing order "may resume all pre-op medications". Both order sections were signed with a date and time by a physician, and initialed with a date and time by RN. Further review of MR12 revealed "Post-Anesthesia Record", MR12 received 50cc of NSS infused in PACU.
Interview on March 11, 2026, with EMP2 at 2:40 PM confirmed the above findings.
Plan of Correction:The Governing Board was made aware of survey finds via ad hoc meeting on March 24, 2026. A Plan of Correction was created and approved to include the following:
Education on safe medication management, pharmaceutical education and completion and documentation of physician orders will be reviewed with the credentialed providers and nursing staff on March 26, 2026, via staff meeting and follow up email. Attendees and education contents will be documented in the staff meeting minutes and clinical in-service documentation.
1) All medication and IV orders will be defined and documented in Preop, OR and PACU to include:
a) Solution to be used for IV Fluids, Rate of IV fluid to be stated in definitive flow rates and volume
parameters of fluids to be infused and IV catheter size as appropriate.
b) Define order to include discontinue of IV therapy when established discharge is met
c) All pre-defined orders on the sheet will be checked off and signed by an appropriate physician or CRNA.
Orders will be signed off and documented as completed, as appropriate, by nursing staff. This will
include IV starts in all departments.
2)Audits specifically reviewing all chart orders for revised criteria will be audited until one hundred percent compliance is achieved for a minimal sustained period of four weeks. The audit will begin on March 27, 2026. If one hundred percent compliance is not achieved, an additional eight weeks of audits will be completed. Once compliance is achieved, five percent of random medical records will be audited monthly for compliance with results reported to the Medical Advisory Committee quarterly.
3) Director of Nursing will ensure completion of audits and compliance with documentation requirements is sustained. All findings will be reported to the Quality Committee, Medical Advisory Committee, and Governing Board during quarterly meetings.
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