QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:

This report is the result of an unannounced revisit survey conducted on May 10, 2024, following a State Licensure survey completed on January 18, 2024, at Berkshire Eye Surgery Center. It was determined that 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:

Exceptions - Principle

Name - Component - 00
51.31. Principle

The Department may grant exceptions to this part when the policy and objectives contained therein are
otherwise met, or when compliance would create an unreasonable hardship and an exception would not impair or endanger the health, safety or welfare of a patient or resident. No exceptions or departures from this part will be granted if compliance with the requirement is provided for by statute.


Based on a review of facility documents and interview with staff (EMP), it was determined that Berkshire Eye Surgery Center failed to comply with requirements, as outlined in the letter from the Department, granting the Exception related to administrative responsibilities.

Findings include:

Review of the document approving the exception request granted by the "Department", dated April 25, 2006, revealed "... The Department of Health is in receipt of your request for an exception to 28 Pa. Code 553.31(a), relating administrative responsibilities. You specifically requested that the facility Administrator and the Director of Nursing be the same individual at the Berkshire Eye Surgery Center (BESC). ... In your request, you stated that BESC is an ASF with two operating rooms and one procedure room. Staffing at the present time consists of five full-time clinical staff, one part-time clinical staff, two full-time business office staff and one full-time RN director (that individual to serve as the Administrator and the Director of Nursing). At present, the operating room time is approximately 16 hours per week. Based on that information, your request is granted. The Department expects that when patient volumes and operating room times increase, a full-time Administrator will be hired. The Department of Health reserves the right to revoke the exception for justifiable reason. ..."

An interview conducted with EMP1 on May 10, 2024, revealed the facility continues to share administrative responsibilities. The facility has submitted a revised exception to the Department.

Plan of Correction:

TAG S 0043
The plan of correction is prepared in compliance with state/federal regulations and is intended as Berkshire Eye Surgery Center's (the "center") credible allegation of compliance. The submission of the plan of correction is not an admission by the facility that it agrees that the citations are correct or that it violated the law.
Organization Minutes:
The confidential and privileged minutes are being retained at the facility for agency review and verification if required.
All exhibits including revisions to Medical Staff Bylaws, reviewed/revised or promulgated policies and procedures, documentation of staff and medical staff training/education are retained at the facility for agency review and verification upon request.
Tag: S 0043 51.31 Exceptions
Policy & Procedures:
The Clinical Director reviewed "Administrative Services" policy to confirm it meets standards and regulations. There were no revisions to the policy required.
Completion date: 5/14/2024
Other Corrective Actions:
1. Current Administrator/Clinical Director will become the full time Interim Administrator after Governing Body approval.
2. Current RN staff member will become the Interim Clinical Director after Governing Body approval.
3. Market recruiter will continue recruitment for full time Administrator position.
Completion date: 5/31/2024
1. Interim Administrator will orient Interim Clinical Director to the role.
Completion date: 6/14/2024
Governing Body will review all DOH exceptions annually at the first quarter meeting.
Completion date: First quarter Governing Body Meeting January 2025 ongoing

Responsible Person(s):
Regional Vice President
Regional Chief Executive Officer
Disciplinary Action:
Non-compliance with corrective action by center staff will result in immediate remediation and appropriate disciplinary action in accordance with the center's Human Resources policies and procedures.