Initial Comments:
This report is the result of a full State Licensure survey initiated on May 5, 2026, and concluded offsite on May 6, 2026, at Fertility Partners of Pennsylvania Surgery Center, LLC. 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:
555.2 LICENSURE
Medical staff membership
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555.2 Medical Staff Membership
A member of the medical staff shall be qualified for membership and the exercise of clinical privileges granted to him. The governing body of the ASF, after considering the recommendations of the medical staff, may grant clinical privileges to qualified, licensed practitioners in accordance with their training, experience and demonstrated competence and judgement. Members of the medicals staff and others granted clinical privileges shall currently hold licenses to practice in this Commonwealth.
Observations:
Based on review of facility documents, credential files (CF) and interview with staff (EMP), it was determined the facility failed to ensure the clinical privileges approved to providers were limited to the scope of the license granted to the facility by the Department of Health for eight of ten credential files reviewed (CF3, CF4, CF5, CF6, CF7, CF8, CF9 and CF10).
Findings include:
Review of the facility's "Medical Staff Bylaws" approved January 5, 2024, revealed "E.The Joint Practice Management Board, as the Governing body, will review each applicant's investigative report complied by the Medical Staff Committee and will ratify the approval or denial of privileges. The Medical Director is an authorized signatory for medical and clinical matters ratified by the Joint Practice Management Board and will sign this approval or denial ..."
Review of facility's "Medical Staff Rules and Regulations" approved January 5, 2024, revealed "General All active medical Staff Members files containing proper credentials will be kept on file at the Chesterbrook location. The files will be readily accessible at all times. Admission and Discharge Fertility Partners of Pennsylvania Surgery Center will only admit patients for purpose of consultations, follow-up visits, or diagnostic or therapeutic fertility, reproductive medicine, or urology procedures ..."
Review on May 5, 2026, of CF3, revealed CF3 received approval for "Telemedicine/Telehealth" privileges on August 15, 2025.
Review on May 5, 2026, of CF4, revealed CF4 received approval for "Telemedicine/Telehealth" privileges on June 5, 2024.
Review on May 5, 2026, of CF5, revealed CF5 received approval for "Telemedicine/Telehealth" privileges on July 9, 2025
Review on May 5, 2026, of CF6, revealed CF6 received approval for "Telemedicine/Telehealth" privileges on December 10, 2025.
Review on May 5, 2026, of CF7, revealed CF7 received approval for "Telemedicine/Telehealth" privileges on November 5, 2025.
Review on May 5, 2026, of CF8, revealed CF8 received approval for "Telemedicine/Telehealth" privileges on November 13, 2025.
Review on May 5, 2026, of CF9, revealed CF9 received approval for "Telemedicine/Telehealth" privileges on June 4, 2025.
Review on May 5, 2026, of CF10, revealed CF10 received approval for "Telemedicine / Telehealth" privileges on June 4, 2025.
Interview with EMP1 on May 5, 2026, revealed the facility does not have approval from the Department of Health to provide Telemedicine/Telehealth services. EMP1 further verified the facility does not provide the above services at the facility.
Plan of Correction:The facility immediately conducted a review of credential files CF3, CF4, CF5, CF6, CF7, CF8, CF9, and CF10 to identify clinical privileges that exceeded the scope permitted under the facility's license. Any privileges identified as outside the scope of the facility license was removed from the affected providers' delineation of privileges forms. Updated privilege forms were reviewed and approved by the Medical Director and Governing Body. The facility also completed an individual review of all active providers to ensure their approved privileges align with the services authorized under the facility license.
The facility implemented an immediate hold on approval of any new or revised clinical privileges until verification is completed against the facility's license and approved scope of services. The Medical Director, Credentialing Coordinator, and Administrator were educated regarding the requirement that all provider privileges must remain within the scope of services authorized by the facility license.
The facility verified that no patients were adversely affected by the previously approved privileges outside the licensed scope.
The facility revised its credentialing and privileging policy to include:
A mandatory crosswalk review between requested privileges and the facility's licensed scope of services prior to approval;
A standardized privileging checklist to be completed during initial appointment and reappointment;
Required review and sign-off by the Credentialing Coordinator, Medical Director, and Governing Body prior to granting privileges;
Annual review of the facility license and approved service lines to ensure ongoing compliance.
Additionally, the facility will maintain a master list of approved clinical services permitted under the Department of Health license to be used during all credentialing and privileging activities.
The facility's Quality Assurance/Performance Improvement (QAPI) Committee will conduct monthly audits of 100% of newly credentialed and recredentialed provider files for a period of three months to verify that approved privileges remain within the licensed scope of services starting on 5/22/2026.
Following the initial three-month period, quarterly audits will be conducted for the next nine months.
Audit findings will be reported to the Governing Body, and corrective action will be implemented immediately for any identified discrepancies.
567.41 LICENSURE
MAINTENANCE SERVICE - Principle
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567.41 Principle
The ASF shall be equipped, operated and maintained to sustain its
safe and sanitary characteristics and to minimize health hazards in the ASF
for the protection of patients and employes.
Observations:
Based on review of the Pennsylvania Code for Labor and Industry, observation, and interview with staff (EMP), it was determined the facility failed to ensure the autoclave used for sterilization of surgical supplies was inspected.
Findings include:
Review on May 6, 2026, of the Pennsylvania Code for Labor and Industry, 34 3a. revealed 3a.168. Autoclaves and quick opening vessels.
(a) An inspector shall inspect autoclaves and quick opening vessels with close examination of all moving parts, locking devices, pins, and interlocking devices, in accordance with ANSI/NB 23.
(b) An autoclave and quick opening vessel must have interlocking systems to prevent charging the vessel until all openings and locking devices are fully in place.
(c) A pressure-relieving device must be sized in accordance with the data plate for pressure. The capacity must be based on the pressure and pipe size or the total BTU valve of the boiler. (d) Inspection of autoclaves and quick opening vessels shall be performed in accordance with 3a.111(8) (relating to field inspections).
Observation on May 5, 2026, of the facility's sterilization area revealed two Tuttnauer autoclaves. The autoclaves are used for sterilization of surgical supplies.
A request was made on May 5, 2026, for documentation of the current boiler/pressure vessel inspections. The provided documents all expired February 1, 2025.
Interview with EMP1 on May 5, 2026, confirmed the above findings.
Plan of Correction:The facility recognizes it is not in compliance with 567.41 (d). The facility immediately contacted a certified boiler inspector (Andrew Foster) at the Department of Labor & Industry on 5/06/2026 to schedule an inspection for two autoclaves. The boiler inspection of two autoclaves was completed on 5/12/2026. Copies of inspection certificates and related documentation will be available by 06/30/2026. The facility reviewed all equipment requiring state inspections to verify no additional inspections are needed. A preventative compliance tracking system was put in place by creating a master inspection log binder. The binder will be reviewed by the Clinical Director yearly, and a 90-day expiration automated notification will be sent to the Clinical Director to schedule a re-inspection.
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