Initial Comments:
This report is the result of a full Medicare recertification survey initiated on March 18, 2026, and concluded on March 25, 2026, at Southwestern Ambulatory Surgery Center. It was determined the facility was in substantial compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions of Participation for Ambulatory Surgical Centers.
Plan of Correction:
416.42(b) & (c) STANDARD
ADMINISTRATION OF ANESTHESIA
Name - Component - 00
b) Anesthetics must be administered by only:
(1) A qualified anesthesiologist; or
(2) A physician qualified to administer anesthesia, a certified registered nurse anesthetist (CRNA) or an anesthesiologist's assistant as defined in §410.69(b) of this chapter, or a supervised trainee in an approved educational program. In those cases where a non-physician administers the anesthesia, unless exempted in accordance with paragraph (c) of this section, the anesthetist must be under the supervision of the operating physician, and in the case of an anesthesiologist's assistant, under the supervision of an anesthesiologist.
(c) State Exemption
(1) An ASC may be exempted from the requirement for physician supervision of CRNAs as described in paragraph (b)(2) of this section, if the State in which the ASC is located submits a letter to CMS signed by the Governor, following consultation with the State's Boards of Medicine and Nursing, requesting exemption from physician supervision of CRNAs. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interests of the State's citizens to opt-out of the current physician supervision requirement, and that the opt-out is consistent with State law.
(2) The request for exemption and recognition of State laws, and the withdrawal of the request may be submitted at any time, and are effective upon submission.
Observations:
Based on a review of facility policy, credential files (CF), and employee interview (EMP), it was determined the facility failed to appoint privileging to physicians who may act in a supervisory role for Certified Registered Nurse Anesthetists (CRNAs) for eight of eight physician credential files reviewed (CF1, CF2, CF3, CF4, CF7, CF8, CF9, CF10).
Findings include:
On March 18, 2026, a review of facility document "Medical Staff Bylaws," last revised 10/2021, revealed "... ARTICLE II ... 2.4 Basic Responsibilities of Medical Staff Membership. The ongoing responsibilities of each member of the medical staff include: ... f) complying with the federal and state laws and regulations governing health care providers, ... ARTICLE III - Appointment and Reappointment ... 3.4.2 Applicant's Burden and Responsibility. The applicant will have the burden of producing adequate information for proper evaluation of his/her competence ... and any other qualifications. ... The information will include but is not limited to the following, ... and complete photo static copies: ... i ) previous practice data, including information on qualifications for privileges applied for; ... l ) specific clinical privileges desired (Delineation of Privileges); includes acting in cooperation with a CRNA when an anesthesiologist is not present according to State Regulations ..."
On March 18, 2026, interview with EMP1 revealed the facility utilizes a CRNA-only model for the provision of anesthesia services. There is no anesthesiologist who is employed by or contracted to work for the facility.
On March 18, 2026, a review of CF1 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF1.
On March 18, 2026, a review of CF2 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF2.
On March 18, 2026, a review of CF3 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF3.
On March 18, 2026, a review of CF4 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF4.
On March 18, 2026, a review of CF7 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF7.
On March 18, 2026, a review of CF8 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF8.
On March 18, 2026, a review of CF9 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF9.
On March 18, 2026, a review of CF10 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF10.
On March 25, 2026, at approximately 10:30 AM, EMP1 confirmed the facility did not appoint privileges to their physicians for the supervision of CRNAs administering anesthetics during surgery, and that Pennsylvania has not been granted exemption from the federal requirement for physician supervision of CRNAs administering anesthesia, as of March 2026.
Plan of Correction:Tag: 0063
A.Policy & Procedures:
Medical Staff Bylaws- A delineation of privileges form addressing the required "supervision of anesthesia" will be established. The form will define the degree of supervision required by varying types of providers and the corresponding scope of responsibilities delegated to certified nurse anesthetists, as well as the corresponding responsibilities of the supervising physicians per CMS requirements.
Completion date: 6/30/2026
Other Corrective Actions:
B.The delineation of privileges form will be presented to the Medical Executive Committee and Governing Body, by the Administrator and Governing Body Chairperson for review and approval.
C. Once approved, this form will be presented to each provider for completion during interim appointment periods and upon initial appointment and reappointment.
Completion date: 6/30/2026
D.Training: Formal education regarding this process change will be communicated to the CRNAs and will include their specific responsibilities in cooperation with the supervising surgeon's scope of privileges. CRNAs will be required to formally attest to their receipt and understanding of this education.
Completion date: 6/30/2026
Monitoring:
The formal attestations will be reviewed for 100% return and compliance.
Completion date: 6/30/2026
Responsible Person: Administrator
416.45(c) STANDARD
OTHER PRACTITIONERS
Name - Component - 00
If the ASC assigns patient care responsibilities to practitioners other than physicians, it must have established policies and procedures, approved by the governing body, for overseeing and evaluating their clinical activities.
Observations:
Based on a review of facility policy, credential files (CF), and employee interview (EMP), it was determined that the facility failed to define individual supervisory responsibilities for physicians who may act in a supervisory role with Certified Registered Nurse Anesthetists (CRNAs) as required by facility bylaws.
Findings include:
On March 18, 2026, a review of facility document "Medical Staff Bylaws," last revised 10/2021, revealed "... ARTICLE II ... 2.4 Basic Responsibilities of Medical Staff Membership. The ongoing responsibilities of each member of the medical staff include: ... f) complying with the federal and state laws and regulations governing health care providers ... ARTICLE III - Appointment and Reappointment ... 3.4.2 Applicant's Burden and Responsibility. The applicant will have the burden of producing adequate information for proper evaluation of his/her competence ... and any other qualifications. ... The information will include but is not limited to the following, ... and complete photo static copies: ... i ) previous practice data, including information on qualifications for privileges applied for; ... l ) specific clinical privileges desired (Delineation of Privileges); includes acting in cooperation with a CRNA when an anesthesiologist is not present according to State Regulations ..."
On March 18, 2026, interview with EMP1 revealed the facility utilizes a CRNA-only model for the provision of anesthesia services. There is no anesthesiologist who is employed by or contracted to work for the facility.
On March 18, 2026, a review of ten credential files included eight physicians and two CRNAs. Of the eight physician files reviewed, zero files included information pertaining to the role and/or requirements in acting as a supervisory physician of CRNAs during administration/maintenance of anesthesia during surgery (CF1, CF2, CF3, CF4, CF7, CF8, CF9, CF10).
No additional document or policy was provided by the facility which defined the individual responsibilities of the supervising physician during administration of anesthesia by CRNAs.
On March 25, 2026, at approximately 11:00 AM, during employee interview, EMP1 confirmed the facility has not defined the degree of supervision required by the assigned physician for any surgical procedure performed in this center.
Plan of Correction:Tag 0123
Policy & Procedures:
A.The Medical Staff Bylaws will be revised to reflect that applicants for the "supervision of anesthesia" delineation of privileges role will be individually reviewed and appointed in accordance with other position-specific set of privileges.
B.A facility policy will be developed which will define the individual responsibilities of the supervising physician during administration of anesthesia by Certified Nurse Anesthetists.
Completion date: 6/30/2026
Other Corrective Actions:
B. The revised Medical Staff Bylaws will be presented to the Medical Executive Committee and Governing Body, by the Administrator and Governing Body Chairperson for review and approval.
Completion timeline: 6/30/2026.
Training: All medical staff/CRNAS including contracted or employed will be formally notified and must sign an attestation that they are in understanding of this Medical Staff Bylaws revision and policy effective on 6/15/2026 and completed by this date 6/30/2026
Monitoring:
The formal attestations will be reviewed by the Administrator for 100% return and compliance.
Completion date: 6/30/2026
Responsible Person: Administrator
Initial Comments:
This report is the result of a full State Licensure survey initiated on March 18, 2026, and concluded on March 25, 2026, at Southwestern Ambulatory Surgery Center. 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 (5)(i)(ii) LICENSURE
Governing Body Responsibilities
Name - Component - 00
Governing Body responsibilities include:
(5) Adopting bylaws or similar rules and regulations for the orderly development and management of the ASF, which:
(i) Describe the authority delegated to the person in charge and to the medical staff.
(ii) Require the governing body to review and approve the bylaws, or similar rules and regulations, of the medical staff.
Observations:
Based on a review of facility policy, credential files (CF), and employee interview (EMP), it was determined the facility failed to appoint privileging to physicians who may act in a supervisory role for Certified Registered Nurse Anesthetists (CRNAs) as required by facility policy for eight of eight physician credential files reviewed (CF1, CF2, CF3, CF4, CF7, CF8, CF9, CF10).
Findings include:
On March 18, 2026, a review of facility document "Medical Staff Bylaws," last revised 10/2021, revealed "... ARTICLE II ... 2.4 Basic Responsibilities of Medical Staff Membership. The ongoing responsibilities of each member of the medical staff include: ... f) complying with the federal and state laws and regulations governing health care providers, ... ARTICLE III - Appointment and Reappointment ... 3.4.2 Applicant's Burden and Responsibility. The applicant will have the burden of producing adequate information for proper evaluation of his/her competence ... and any other qualifications. ... The information will include but is not limited to the following, ... and complete photo static copies: ... i ) previous practice data, including information on qualifications for privileges applied for; ... l ) specific clinical privileges desired (Delineation of Privileges); includes acting in cooperation with a CRNA when an anesthesiologist is not present according to State Regulations ..."
On March 18, 2026, interview with EMP1 revealed the facility utilizes a CRNA-only model for the provision of anesthesia services. There is no anesthesiologist who is employed by or contracted to work for the facility.
On March 18, 2026, a review of CF1 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF1.
On March 18, 2026, a review of CF2 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF2.
On March 18, 2026, a review of CF3 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF3.
On March 18, 2026, a review of CF4 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF4.
On March 18, 2026, a review of CF7 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF7.
On March 18, 2026, a review of CF8 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF8.
On March 18, 2026, a review of CF9 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF9.
On March 18, 2026, a review of CF10 revealed no request for privileges related to the supervision of CRNAs administering anesthetics, nor evidence of approval for this privilege designated to CF10.
On March 25, 2026, at approximately 10:30 AM, EMP1 confirmed the facility did not appoint privileges to their physicians for the supervision of CRNAs administering anesthetics during surgery, and that Pennsylvania has not been granted exemption from the federal requirement for physician supervision of CRNAs administering anesthesia, as of March 2026.
Plan of Correction:Policy & Procedures:
A.A Director of Anesthesia role will be appointed by the Medical Executive Committee and Governing Body to provide physician oversight and supervision for anesthesia services. This oversight will include the appointment of supervising surgeons of nurse anesthetists, approval of supervising surgeon privileges and CRNA privileges for anesthesia.
B.The Medical Staff Bylaws will be revised to reflect that applicants for the "supervision of anesthesia" delineation of privileges role will be individually reviewed and appointed in accordance with other position-specific set of privileges.
C.A facility policy will be developed which will define the individual responsibilities of the supervising physician during administration of anesthesia by CRNAs.
Completion timeline: 6/1/2026
Other Corrective Actions:
Revision of organizational chart to reflect the Director of Anesthesia role and approval by Medical Executive Committee and Governing Body Committee.
The Director of Anesthesia position will be appointed by the Medical Executive Committee and Governing Body Committee on an annual basis.
Completion timeline: 6/1/2026
Training:
A notification and attestation of the revised bylaws "regarding supervision of anesthesia" and the related new facility policy will be distributed to the Medical Staff for review and acknowledgment.
Monitoring:
The formal attestations will be reviewed by the Administrator for 100% return and compliance.
Completion date: 6/30/2026
Responsible Person: Administrator
555.31 (b) LICENSURE
Anesthesia Services
Name - Component - 00
Anesthesia Services
555.31 Principle
(b) The governing body shall define the degree of supervision required and the scope of responsibilities delegated to anesthesiologists, certified registered nurse anesthetists and dentist anesthetists, as well as the corresponding responsibilities of supervising physicians.
Observations:
Based on a review of facility policy, credential files (CF), and employee interview (EMP), it was determined that the facility failed to define individual supervisory responsibilities for physicians who may act in a supervisory role with Certified Registered Nurse Anesthetists (CRNAs) as required by facility bylaws and in accordance with state and federal regulations.
Findings include:
On March 18, 2026, a review of facility document "Medical Staff Bylaws," last revised 10/2021, revealed "... ARTICLE II ... 2.4 Basic Responsibilities of Medical Staff Membership. The ongoing responsibilities of each member of the medical staff include: ... f) complying with the federal and state laws and regulations governing health care providers ..."
On March 18, 2026, a review of the facility document "Medical Staff Bylaws," last revised 10/2021, revealed "... ARTICLE III - Appointment and Reappointment ... 3.4.2 Applicant's Burden and Responsibility. The applicant will have the burden of producing adequate information for proper evaluation of his/her competence ... and any other qualifications. ... The information will include but is not limited to the following, ... and complete photo static copies: ... i ) previous practice data, including information on qualifications for privileges applied for; ... l ) specific clinical privileges desired (Delineation of Privileges); includes acting in cooperation with a CRNA when an anesthesiologist is not present according to State Regulations ..."
On March 18, 2026, a review of the Centers for Medicare & Medicaid Services, State Operations Manual (SOM) Appendix L - Guidance for Surveyors: Ambulatory Surgical Centers, Rev. 215, July 21, 2023, Section and the interpretive guidelines revealed "... The ASC must specify the anesthesia privileges for each practitioner who administers anesthesia, or who supervises the administration of anesthesia by another practitioner. The privileges must be granted in accordance with State law and the ASC's policy. The type and complexity of procedures for which the practitioner may administer anesthesia or supervise another practitioner ... must be specified in the privileges granted to the individual practitioner. ... If the ASC is located in a State where the Governor has submitted a letter to CMS attesting that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State, and has concluded that it is in the best interests of the State's citizens to opt-out of the current physician supervision requirement, and that the opt-out is consistent with State law, then a CRNA may administer anesthesia without physician supervision."
On March 18, 2026, during interview with EMP1, it was revealed that the facility utilizes a CRNA-only model for the provision of anesthesia services. There is no anesthesiologist who is employed by or contracted to work for the facility.
On March 18, 2026, a review of ten credential files included eight physicians and two CRNAs. Of eight physician files reviewed, zero files included information pertaining to the role and/or requirements in acting as a supervisory physician of CRNAs during administration/maintenance of anesthesia during surgery (CF1, CF2, CF3, CF4, CF7, CF8, CF9, CF10).
No additional document or policy was provided by the facility which defines the individual responsibilties of the supervising physician during administration of anesthesia by CRNAs.
On March 25, 2026, at approximately 11:00 AM, during employee interview, EMP1 confirmed that the facility has not defined the degree of supervision required by the assigned physician for any surgical procedure performed in this center.
Plan of Correction:State DOH Findings TAG 5552
Policy & Procedures:
A.The Governing Body Bylaws will be revised to define the degree of supervision required and the scope of responsibilities delegated to certified nurse anesthetists, as well as corresponding responsibilities of supervising physicians.
B. In accordance with the Governing Body Bylaws, the delineation of privileges form regarding the "supervision of anesthesia" will be established. The form will define the degree of supervision required by varying types of providers and the scope of responsibilities delegated to certified nurse anesthetists, as well as corresponding responsibilities of the supervising physicians per CMS requirements.
Completion timeline: 6/30/2026
Other Corrective Actions:
A. The delineation of privileges will be presented to the Medical Executive Committee and Governing Body, by the Administrator and Governing Body Chairperson for review and approval.
B. Once approved, this form will be presented to each provider for completion during interim appointment periods and upon initial appointment and reappointment.
C.A facility policy will be developed which will define the individual responsibilities of the supervising physician during administration of anesthesia by certified nurse anesthetists.
Completion date: 6/30/2026
D.Training: A formal attestation of this process change will be communicated to the CRNAs and will include their specific responsibilities in cooperation with the supervising surgeon's scope of privileges.
Monitoring:
Formal education regarding this process change will be communicated to the CRNAs, which will include their specific responsibilities in cooperation with th supervising surgeons. CRNAs will be required to formally attest to their receipt and understanding of this education. Attestations will be reviewed by the Administrator for 100% return and compliance.
Completion date: 6/30/2026
Responsible Person: Administrator
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