Initial Comments:
This report is the result of a full State Licensure survey completed on May 12, 2025 at Allegheny Health Network- Bethel Park 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:
51.31 LICENSURE
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.
Observations:
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to comply with the required criteria as stated in the exception granted by the Department related to the integration of the Allegheny Health Network Surgery Center Governing Body.
Findings include:
On May 12, 2025, a review of the approved exception request letter, dated July 31, 2023 as sent to Allegheny Health Network Surgery Center- Bethel Park, revealed, that the facility requested and was granted an exception to: 28 Pa. Code 553.1. "Conditions: The request related to Governing Body is granted based on the information provided in the narrative submitted. Allegheny Health Network Monroeville Surgery Center must be specifically addressed in the Allegheny Health Network bylaws of the governing body. All the bylaws of the Allegheny Health Network will apply to the ASF unless specifically stated otherwise. The governing body minutes must reflect the activities of the ASF ...".
On May 12, 2025, a review of the minutes of the August 26, 2024 Governing Body Meeting revealed that Quality and Safety indicators for the Allegheny Health Network Surgery Center- Bethel Park were merged into a statistical analysis with 6 other network facilities. Thus, the activities and results of the Allegheny Health Network Surgery Center- Bethel Park Quality and Safety initiatives did not stand alone and were not documented in the minutes.
On May 12, 2025, at 10:30 AM, EMP3 confirmed this finding.
Plan of Correction:This plan outlines the steps Bethel Park Surgery Center will take to address the citation related to the inappropriate aggregation of quality data across all sites within the Ambulatory Surgery Division, rather than presenting site-specific data.
Presentation to Board of Directors
- The basis of this citation, along with this plan of correction, will be presented to the Board of Directors for the Ambulatory Surgery Division at the annual Board meeting at the end of the August / beginning of September 2025.
- Site-specific quality data for Bethel Park ASC will be presented to the Board of Directors at the annual Board meeting. This data will include, but not be limited to, safety data such as wrong site surgeries, falls, transfers, 24-hour ED visits; ASCQR data that is required by CMS.
- Aggregated quality data across the Ambulatory Surgery Division will only be presented for benchmarking purposes. The presentation will clearly state that this data is not intended to evaluate the performance of Bethel Park ASC in isolation.
- The scope and purpose of the data presented, including the clear distinction between site-specific data for Bethel Park ASC and aggregated benchmarking data for the division, will be accurately documented in the meeting minutes.
Board Meeting Minutes will be reviewed to assure site specific information is discussed per the exception requirements.
This will be audited once as there is only one Board of Directors meeting where all information is discussed.
Plan of Correction Date: June 30,2025
553.3 (13)(i-iv) LICENSURE
Govern Body Responsibilities
Name - Component - 00
Governing Body responsibilities include:
(13) Approving major contracts or arrangements affecting the medical care provided under its auspices, including, those concerning;
(i) The employment for contractual arrangements with practitioners and others providing direct patient care.
(ii) The provision of all treatment related services including, radiology, medical laboratory, pathology , anesthesia and pharmaceutical services.
(iii) The provision of care by other health care organizations.
(iv) The provision of education to students and post graduate trainees.
Observations:
Based on a review of facility documents and staff interviews (EMP), it was determined that the governing body failed to amend the Master Services Agreement with Allegheny Health Network to include the services of AHN Infection Control Director and the Infection Prevention Manager from Jefferson Hospital.
Findings include:
On May 12, 2025, a review of Infection Control and Prevention Plan-Monroeville Ambulatory Surgery Center 2024 (Last Reviewed: 08/26/2024) was completed and revealed the following: "II. FUNDAMENTALS: A. Governing Body / IC&P Reporting Structure: The ASC Board of Managers delegates authority for oversight of the IC&P program to the AHN BPSC Infection Prevention Committee (IPC). The ASC Board of Manager's delegates authority for the development, implementation, monitoring, and enforcement of the IC&P program to the AHN MASC Infection Preventionists (IPs). B. Infection Prevention - AHN Infection Control Director: Provides AHN guidance for the function of infection prevention; Oversees all network Infection Prevention personnel and budget activities; Participates in the review and approval of all infection prevention policies and plans to ensure standardization of best practices across the network and alignment with national standards for IP practices; Participates in the AHN Peri-Op CARE Committee in reviewing and approving products for use at AHN ... Infection Prevention Committee (IPC): Ultimate responsibility for overseeing and implementing the infection control and prevention plan is delegated by the governing body to the Infection Prevention Committee. Committee membership includes, but may not be limited to: Jefferson Hospital Members: ...Infection Prevention Manager ...".
On May 12, 2025, a review of the Master Services Agreement- Ambulatory Surgery Centers (Effective January 1, 2025) was completed and revealed that Infection Control services from the AHN Infection Control Director or the Jefferson Hospital Infection Prevention Manager were not included in the agreement.
On May 12, 2025, at approximately 2:00 PM, EMP1 confirmed that Infection Control Services were not included Master Services Agreement.
Plan of Correction:Plan of Correction:
1. Immediate Action:
o Bethel Park Ambulatory Surgery Center (BPSC) Infection Control and Prevention Plan will be immediately revised to accurately reflect the current operational structure. Specifically, all references to an affiliation with Jefferson Hospital infection control department will be removed.
2. Review and Approval Process:
o The revised Infection Control and Prevention Plan will be presented to the following committees for review and approval:
Infection Control Quarterly Meeting
Quality Meeting
Medical Executive Committee Meeting
3. Governing Body Approval:
o Following approval from the above-mentioned committees, the final revised Infection Control and Prevention Plan will be presented to the Board of Managers for final approval at its annual meeting in September 2025.
4. Implementation Date:
o The revised Infection Control and Prevention plan will be implemented immediately following the Board of Manager's approval.
5. Monitoring:
o Compliance with the revised Infection Control and Prevention Plan will be a standing agenda item at the Quarterly Infection Control and Quality Meetings.
o The administrator will oversee the compliance
Date of Completion:June 30, 2025
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