Initial Comments:
This report is the result of a full State Licensure survey initiated on and concluded on February 11, 2026, at King of Prussia Surgical 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:
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 documents and interview with staff (EMP), it was determined the facility failed to conform to an applicable State regulation.
King of Prussia Surgery Center, Llc 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.
Findings include:
Review on February 11, 2026, of the facility's policy "Patient Safety Plan" Board Approved January 12, 2025 reveals, "The Patient Safety Committee i. shall, at minimum, be composed of the PSO (Patient Safety Officer), a member of the medical staff, a community member, the chair of the QAPI committee and a member of staff."
Review on February 11, 2026, of the facility's "Patient Safety Committee Meeting Minutes" dated October 27, 2025, revealed no documented evidence that a resident of the community was in attendance at the October 2025 meeting.
Review on February 11, 2026, of the facility's "Patient Safety Committee Meeting Minutes" dated January 28, 2026, revealed no documented evidence that a resident of the community was in attendance at the January 2026 meeting.
Interview on February 11, 2026, at 1:00 PM, with EMP1 confirmed the above findings.
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Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to an applicable State regulation.
King of Prussia Surgery Center, Llc was not in compliance with the following State law:
Act 52 of 2007 Medical Care Availability and Reduction of Error (MCARE) Act Chapter 4 ... 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 meetings.
Findings include:
Review on February 11, 2026, of the facility's policy "Infection Prevention Annual Plan" reviewed January 28, reveals, "... DEVELOPMENT OF GOALS A. King of Prussia Surgery Center establishes priorities and sets goals for preventing the development of healthcare-associated infections within the facility based on risks identified in the Infection Prevention Risk Assessment. In order to continue to excellence in patient care, the following infection control goals have been established: ... 8. To comply with all relevant state and federal laws and accrediting body standards. "
Review on February 11, 2026, of the facility's "Infection Control Committee Meeting Minutes" dated October 27, 2025, revealed no documented evidence that a resident of the community was in attendance at the October 2025 meeting.
Review on February 11, 2026, of the facility's "Infection Control Committee Meeting Minutes" dated January 28, 2026, revealed no documented evidence that a resident of the community was in attendance at the January 2026 meeting.
Interview on February 11, 2026, at 1:00 PM, with EMP1 confirmed the above findings.
Plan of Correction:1. A community member was secured and documented via email on 03/01/2026 for all future Patient Safety and Infection Control Meetings, the facility will appoint a qualified resident of the community served by the surgery center who is not an agent, employee, or contractor of the facility to serve on the Patient Safety Committee and Infection Control Committees.
2. Documentation of the appointment of the community member will be included in the 2026 Q2 Patient Safety and Infection Prevention Meeting Minutes.
3. Meeting minute templates will be revised to include a required attendance section identifying the community member by name and role.
4. The Administrator or designee will implement a standardized committee compliance checklist to be completed prior to finalizing each meeting agenda.
5. Attendance verification will be reviewed and confirmed before meeting adjournment.
Monitoring Plan
1. The Administrator will audit 100% of Patient Safety and Infection Control Committee meeting minutes for 1 year to ensure community member attendance is documented.
2. Audit results will be reported quarterly to the QAPI/MEC Committee.
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