Hearth Record

West Penn Hospital

An acute care hospital in Pittsburgh, Pennsylvania 15224

4800 Friendship Avenue, Pittsburgh, Pennsylvania 15224. (412) 578-5000.

  • Medicare payments cut under the HAC Reduction Program (fiscal year 2026)
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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 3 deficiencies in 1 month of the last 36. Last cited Apr 2024. Most serious: Standard-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.

What did inspectors find?

The last inspection on record was on Apr 3, 2024: a complaint inspection.

3 deficiencies cited in the last three years.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

3 deficiencies in 1 month of the last 36. Last cited Apr 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.

3 deficiencies by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Apr 3, 2024: complaint inspection3 deficiencies
  • Rn Supervision Of Nursing Care

    The inspectors’ words, 454 words

    “RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 42809 Based on a review of facility documentation, medical records (MR), and staff interviews (EMP) it was determined the facility failed to provide evidence in the medical record that a registered nurse (licensed professional nurse) supervised and evaluated nursing care of each patient for 4 of 20 medical records reviewed. (MR1, MR2, MR7, and MR9). Findings include: On April 3, 2024, review of facility policy, POL 6511361, “Licensed Practical Nurse (LPN) Role “, last approved September 26, 2023, revealed: “ ... It is the policy that AHN utilizes and allows the Licensed Practical Nurse (LPN) to function as a member of the health care team ... The LPN may participate in planning, implementation, and evaluation of nursing care using focused assessment in settings where nursing takes place. ...”. Further review of this policy revealed: “... Terms and Definitions: Focused assessment - Appraisal of an individual’s current status and situation, which contributes to [the] comprehensive assessment by the licensed professional nurse and supports ongoing data collection. ...”. Review of MR1 revealed that the patient was cared for by a licensed practical nurse (EMP6) between February 25, 2024, at 7:00 PM, and February 26, 2024, at 7:00 AM. Further review of MR1 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift. Review of MR2 revealed that the patient was cared for by a licensed practical nurse (EMP11) between March 30, 2024, at 7:00 PM, and March 31, 2024, at 7:00 AM. Further review of MR2 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift. Review of MR7 revealed that the patient was cared for by a licensed practical nurse (EMP11) between March 28, 2024, at 7:00 AM, and March 28, 2024, at 7:00 PM. Further review of MR7 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift. Review of MR9 revealed that the patient was cared for by a licensed practical nurse (EMP11) on March 27, 2024 and March 28, 2024 from 7:00 AM to 7:00 PM. Further review of MR9 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during the shifts(s). The above findings were confirmed for MR1, MR2, and MR7 during MR review with EMP4 on April 3, 2024, between 12:00 PM and 1:50 PM. The above finding for MR9 was confirmed on April 3, 2024, during MR review with EMP5 on April 3, 2024, at 12:21 PM.”

    Rule A0395. Standard-level. From a complaint.

  • Supervision Of Contract Staff

    The inspectors’ words, 1,320 words

    “SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42809 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined licensed nurses providing services in the facility failed to document patient hand-off communication per facility policy for 13 of 20 medical records reviewed (MR1, MR2, MR4, MR5, MR6, MR8, MR9, MR11, MR13, MR16, MR18, MR19, and MR20) Findings include: Review of facility policy, “Patient Hand-Off Communication”, last approved 6/8/2022, revealed: “ ... Overview Statement ... Current, accurate information related to a patient’s care, treatment/services and clinical status will be communicated when transferring the care of a patient between or among members of the heath care team/providers. ... Administration A. Intra-departmental Communication 1. Change of shift report or when care is temporarily assigned to another licensed nurse within the patient care unit. ...”. Review of MR1 revealed no evidence of patient hand-off communication on February 25, 2024, at 7:00 AM. Review of MR2 revealed no evidence of patient hand-off communication on March 30, 2024, at 7:00 PM. Review of MR4 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM. Review of MR5 revealed no evidence of patient hand-off communication on March 25, 2024, at 7:00 AM, and on March 29, 2024, at 7:00 AM. Review of MR6 revealed no evidence of patient hand-off communication on the following dates and times: March 29, 2024 at 7:00 AM March 30, 2024 at 7:00 PM April 1, 2024 at 7:00 AM April 2, 2024 at 7:00 AM Review of MR8 revealed no evidence of patient hand-off communication on the following dates and times: March 31, 2024 at 7:00 AM April 1, 2024 at 7:00 PM April 2, 2024 at 7:00 AM April 3, 2024 at 7:00 AM Review of MR9 revealed no evidence of patient hand-off communicaton on the following dates and times: March 27, 2024 at 7:00 AM April 2, 2024 at 7:00 AM and 7:00 PM April 3, 2024 at 7:00 AM Review of MR11 revealed no evidence of patient hand-off communication on the following dates and times: March 26, 2024 at 7:00 PM March 27, 2024 at 7:00 AM March 28, 2024 at 7:00 PM Review of MR13 revealed no evidence of patient hand-off communication on March 24, 2024, at 7:00 AM. Review of MR16 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM and at 7:00 PM. Review of MR18 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 PM Review of MR19 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM and 7:00 PM. Review of MR20 revealed no evidence of patient hand-off communication on April 1, 2024, at 7:00PM. The above findings for MR1, MR2, MR4, MR5, MR6 and MR8 were confirmed during medical record review with EMP4 on April 3, 2024, between 12:00 PM and 1:50 PM. The above findings for MR9, MR11, MR13, MR16, MR18, MR19, and MR20 were confirmed during medical record review with EMP5 on April 3, 2024, between 12:10 PM and 1:40 PM. -------------------------------------------------------- Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined licensed nurses providing services in the facility failed to document purposeful hourly rounding per facility policy for 13 of 20 medical records reviewed (MR1, MR6, MR8, MR9, MR10, MR11, MR13, MR14, MR15, MR17, MR18, MR19 and MR20). Findings include: Review of facility’s “Purposeful Hourly Rounds”, last approved 7/31/2023, revealed: “ ... The purpose of this policy is provide guidelines for patient care needs that are to be addressed during hourly rounds. ... The RN/GN/LPN/PCTs will: 1. Perform rounds on each patient a. Every 1 hour between the hours of 7am - 11pm b. Every 2 hours between the hours of 12am - 7am. ... 3. Documentation of hourly rounds occurs in the EMR. ...”. Review of MR1 revealed hourly rounds were not documented on February 25, 2024, between 9:00 PM and 7:00 AM. Review of MR6 revealed hourly rounds were not documented on the following dates and times: March 31, 2024 at 1:00 AM and 3:00 AM April 1, 2024 at 1:00 PM, 3:00 PM, 4:00 PM, and 5:00 PM April 2, 2024 at 3:00 AM, 4:00 PM and 5:00 PM Review of MR8 revealed hourly rounds were not documented on the following dates and times: April 2, 2024 between 10:00 AM and 5:00 PM April 1, 2024 between 10:00 AM and 3:00 PM March 31, 2024, between 11:00 AM and 2:00 PM Review of MR9 revealed hourly rounds were not documented on the following dates and times: March 27, 2024 between 11:00 AM and 4:00 PM March 28, 2024 between 10:00 AM and 3:00 PM. March 28, 2024 at 5:00 PM and 6:00 PM. Review of MR10 revealed hourly rounds were not documented on the following dates and times: March 30, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM., 08:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 6:00 PM, 9:00 PM, 10:00 PM, and 11:00 PM. March 31, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM, 9:00 PM, and 10:00 PM. Review of MR11 revealed hourly rounds were not documented on the following dates and times: March 27, 2024 at 2:00 PM March 28, 2024: 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM. Review of MR13 revealed hourly rounds were not documented on the following dates and times: March 24, 2024: 09:00AM, 09:00 PM, 10:00 PM, and 11:00PM March 25, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 8:00 PM, 10:00 PM, and 11:00 PM March 26, 2024: 10:00 PM Review of MR14 revealed hourly rounds were not documented at the following times: March 22, 2024 at 2:00 AM, 4:00 AM, 7:00 AM, 9:00 AM, 10:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM; 5:00 PM, 6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, and 11:00 PM. Review of MR15 revealed hourly rounds were not documented at the following times: April 2, 2024 at 8:00 AM, 9:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00PM, 4;00 PM, 5:00 PM, and 6:00 PM. Review of MR17 revealed that every two hour rounds were not documented at the following times: March 27, 2024 at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM. . Review of MR18 revealed hourly rounds were not documented at the following times: April 2, 2024, at 2:00 PM, 3:00PM, 4;00 PM, 5:00 PM, 10:00 PM, and 11:00 PM. Review of MR19 revealed hourly rounds were not documented at the following times: April 2, 2024, at 07:00 AM, 8:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 3:00PM, 4:00 PM, 5:00 PM, and 6:00 PM. Review of MR20 revealed hourly rounds were not documented at the following times: April 1, 2024, at 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00PM, 4;00 PM, 6:00 PM and 11:00 PM. The above findings for MR1, MR6 and MR8 were confirmed during medical record review with EMP4 on April 3, 2024 between 12:00 PM and 1:50 PM. The above findings for MR9, MR10, MR11, MR13, MR14, MR15, MR17, MR18, MR19 and MR20 were confirmed during medical record review with EMP5 on April 3, 2024 between 12:15 PM and 1:40PM.”

    Rule A0398. Standard-level. From a complaint.

  • Rn Policy For Outpatient Depts

    The inspectors’ words, 191 words

    “RN POLICY FOR OUTPATIENT DEPTS CFR(s): The hospital must have policies and procedures in place establishing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present. The policies and procedures must: (i) Establish the criteria such outpatient departments must meet, taking into account the types of services delivered, the general level of acuity of patients served by the department, and the established standards of practice for the services delivered; (ii) Establish alternative staffing plans; (iii) Be approved by the director of nursing; (iv) Be reviewed at least once every 3 years This Standard is not met as evidenced by: 42809 Based on interview (EMP), it was determined the facility failed to have policies and procedures in place establishing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present. Findings include: During a facility survey on April 3, 2024, the facility was unable provide policies and procedures addressing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present. The above was confirmed with EMP1 on April 3, 2024, at 11:25 AM.”

    Rule A0399. Standard-level. From a complaint.

The one inspection in the last three years
Inspections on record
DateVisitWhat the record says
Apr 3, 2024Complaint inspection3 deficiencies cited

How do patients fare?

  • CMS’s overall for it is 3 of 5.
  • Of the measures behind its , CMS counts against the national value: mortality, 0 better and 0 worse of 5; safety of care, 0 better and 1 worse of 7; readmission, 1 better and 1 worse of 7.
  • Patients rate it 4 of 5 in CMS’s patient survey (438 surveys completed, Oct 1, 2024 to Sep 30, 2025): 76% rated it 9 or 10 out of 10, and 77% would definitely recommend it.
  • Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; surgical site infections after abdominal hysterectomy, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
  • CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
  • Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11%, heart failure 9.8%, pneumonia 16%, stroke 11.8%. CMS gives no comparison with the national rate for them in this release.
  • Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 13.6%, heart failure 20.9%, pneumonia 17.2%, COPD 19.8%. CMS gives no comparison with the national rate for them in this release.
  • After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, worse than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
  • Emergency department patients spent a median of 208 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
  • 60% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
  • Medicare’s spending per patient here is 1.07 times the national median (Jan 1, 2024 to Dec 31, 2024).
Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 53 of 5
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 54 of 5

Is it certified, and in good standing?

  • Medicare-certified acute care hospital since Jul 1, 1966.
  • Ownership: voluntary non-profit - private.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • No deficiency on record in the last three years.
  • It has an inpatient rehabilitation unit of 33 beds, which CMS lists apart as a rehabilitation facility.
  • Voluntary non-profit - Private.
Source:

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Has it been penalized?

  • CMS doesn’t publish fines or other penalties for hospitals.
  • CMS cut its Medicare payments by 1% for fiscal year 2026 under the Hospital-Acquired Condition Reduction Program, which does so for the quarter of hospitals that fare worst on conditions patients get in hospital.
  • 3 deficiencies cited in the last three years came from inspections that included a complaint investigation.
Source:

CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

On record, newest first
DateWhatDetail
Medicare payment reduction (HAC Reduction Program)Fiscal year 2026: 1% of Medicare payments

What do patients say about their care?

  • CMS doesn’t publish staffing levels for hospitals.
  • In CMS’s patient survey, patients rate how well its nurses communicated 5 of 5.
  • 50% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • 15 owners or officers are people: Tony G Farah (corporate director); Tony G Farah (managing employee (on the payroll)); Joseph Macerelli (corporate officer); Joseph Macerelli (corporate director); Robert Pompeani (corporate director); Richard Nagy (corporate director); Richard Nagy (managing employee (on the payroll)); Wendy O’brien (corporate director); Kelly A Waldman (corporate director); Jacqueline M Bauer (corporate officer); Jacqueline M Bauer (corporate director); Brian Devine (corporate officer, 0%); Bruce A Meyer (corporate director); Russell Livingston (corporate director); Brian Ice (corporate director).
  • CMS’s Provider of Services file records 1 change of ownership.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

Organisations CMS lists
OrganisationRoleShareSince
West Penn Allegheny Health System, Inc.Other role (CMS gives no detail)Apr 29, 2013
Allegheny Health NetworkOther role (CMS gives no detail)Apr 29, 2013
Highmark HealthOther role (CMS gives no detail)Apr 29, 2013

How does it compare nearby?

  • Of the 18 hospitals CMS lists in Allegheny County, 16 have an overall star rating from CMS: 1 rated 5 of 5, 10 rated 4 of 5, 5 rated 3 of 5.
  • CMS rates this one 3 of 5.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
  • QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
  • CMS doesn’t publish staffing levels for hospitals.
  • In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the hospital

The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.

How to read a record

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An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

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