Penn Highlands Mon Valley
An acute care hospital in Monongahela, Pennsylvania 15063
1163 Country Club Road, Monongahela, Pennsylvania 15063. (724) 258-1000.
- 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.
- 1of 5 CMS’s overall rating
- 2of 5 patient survey rating
- 3 deficiencies cited in the last three years
- 210 beds
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 Jan 22, 2025: a complaint inspection.
3 deficiencies cited in the last three years.
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 Jan 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
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.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Jan 22, 2025: complaint inspection3 deficiencies
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Contracted Services
The inspectors’ words, 217 words
“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 45574 Based upon a review of facility documents and interview (EMP), it was determined that the facility governing body failed to execute a valid contract for teleradiology services. Findings include: On January 22, 2025, a review of the facility “Teleradiology Services Agreement,” executed October 1, 2022, was completed. “ Recitals: A. System is a nonprofit healthcare system comprised of hospitals and other healthcare facilities in and around Western Pennsylvania, including DuBois Hospital, Clearfield Hospital, Elk Hospital, and Brookville Hospital ... “ On August 31, 2022, Amendment 1 was executed and added Penn Highlands Connellsville to the existing teleradiology agreement for the Penn Highlands Healthcare System. However, there was no existing amendment to the “Teleradiology Services Agreement” which covers the teleradiology services which are rendered by the contractor at Penn Highlands Mon Valley. On January 22, 2025, EMP2 reviewed the contract and confirmed the above at 2:07 PM.”
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Patient Rights: Care In Safe Setting
The inspectors’ words, 495 words
“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42809 Based on review of facility documentation, medical record (MR), and staff interview (EMP), it was determined that the facility failed to provide care in a safe setting by failing to establish and maintain a reliable system for the timely transfer of images to the teleradiologist for one of one medical records (MR1). Findings include: Review of facility policy “Radiology Requests 1-5”, effective date: 5/13/2024, revealed: “ ... Procedure: Emergency Room requests are entered into the information system as STAT. ... All imaging studies will be requested by their priority set up by the hospital ... STAT (immediately) ... “. Review of facility documentation revealed issues with delayed electronic transmission of imaging results were reported on the following dates and times: January 11, 2025, at 12:30 AM; January 11, 2025, at 9:00 PM; January 12, 2025 at 9:30 AM; January 13, 2025 at 2:30 AM; and January 13, 2025 at 7:10 AM. Review of MR1 revealed a CT and CTA of the head were ordered on January 13, at 12:59 AM. Further review of MR1 revealed that the results of the CT and CTA images were dictated/read by the teleradiologist on January 14, 2025 at 6:20 AM (approximately five and a quarter hour after they were ordered). Based on interview with EMP2 on January 21,2025, at approximately 10:30 AM, the delay in transmission of the images to the teleradiologist contributed to the delay in reading the images for MR1. The above findings related to delayed transmissions of imaging results were confirmed with EMP2 on January 21, 2025, at approximately 10:30 AM, and with EMP11 on January 22, 2025, at 1:45 PM. The above findings related to MR1 were confirmed with EMP6 on January 22, 2025, at approximately 10:50 AM. Based upon observation and staff interview (EMP), it was determined that the facility failed to maintain a clean and safe setting. Findings include: On January 21, 2025, from approximately 12:15 PM to 12:45 PM, an accompanied tour of the first floor Emergency Department and patient rooms was completed. Tour observations revealed the following: Upon arrival to the entrance to the Emergency Department, a ceiling tile was dislodged, and two other ceiling tiles were soiled. Visible debris was hanging from the ceiling tile in the corner near the door at the entrance. One ceiling tile in the area above Security was soiled. Thirty-three light fixtures in the hallway revealed visible debris and dead insects. Rooms three, six, and seven showed visible grey and black debris buildup along the doorway threshold. The floor in room seven had visible areas of yellow staining throughout. Countertops in rooms three and six showed the top layer of laminate worn through, revealing a more porous feeling bottom layer. The above findings were confirmed by EMP2 and EMP6 on January 21, 2025, at 12:35 PM.”
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Integration Of Emergency Services
The inspectors’ words, 435 words
“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 46390 Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to follow hospital policies and procedures by not activating a stroke alert on a patient who presented in the Emergency Department with stroke-like symptoms for one of ten medical records reviewed (MR1). Findings include: On January 21, 2025, a review of the facility policy Emergency Department Documentation of the Emergency Department Electronic Medical Record (EMR) revealed, “To ensure appropriate documentation of all pertinent information related to the patient’s chief complaint and continuing throughout their course of treatment. ....E. The Emergency Department Registered Nurse or Health Care Professional will utilize the Emergency Department Patient Record for initial patient assessment, reassessment, intervention and continued care. F. The frequency of reassessment is based upon the patients’ acuity, condition, history and nursing judgment: Timing of reassessments should reflect the patient’s status at any given moment they are in the treatment area, remembering that a patient’s priority/acuity can change.” On January 21, 2025, a review of facility policy “Handoff Communication for Stroke Patients”, last reviewed September 2022, revealed the following: “... III. Frequency of NIHSS and Vital Signs: ... B. Non Tenecteplase (TNKase) patient [SIC] will have an NIHSS and vital signs performed as follows: (This includes extended stay or boarded patients in the E.D.) 1. Every 4 hours x 48 hours. 2. Daily. 3. Discharge 4. During hand off from one unit to the next. 5. During hand off from one facility to the next.” On January 21, 2025, a review of the facility’s “Acute Stroke Workflow” revealed, “Patient presents with symptoms consistent with acute ischemic stroke within 24 hours of symptom onset, Stroke Alert is Initiated. ED-Stroke Alert Page, Inpatient-RRT Stroke Alert, Initiate ED/Acute Stroke Work UP. Bedside Assessment.” On January 22, 2025, at 11:20 AM, a review of MR1 revealed that the patient presented to the Emergency Department with complaints of a headache, as well as transient left hand numbness and tingling. The patient and family also reported recent nausea, vomiting, and mild photophobia, and confusion. Further review of MR1 revealed no evidence of a stroke alert being called for the patient. A nurses note on January 13, 2025, at 12:55 AM, read “seen by [Emergency Physician] stroke alert not advised”. The above findings were confirmed by EMP6 during employee interview on January 22, 2025, between 11:00 AM and 2:00PM.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jan 22, 2025 | Complaint inspection | 3 deficiencies cited |
How do patients fare?
- CMS’s overall 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. for it is 1 of 5.
- Of the measures behind its 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., CMS counts against the national value: mortality, 0 better and 0 worse of 6; safety of care, 0 better and 0 worse of 7; readmission, 0 better and 2 worse of 6.
- Patients rate it 2 of 5 in CMS’s patient survey (325 surveys completed, Oct 1, 2024 to Sep 30, 2025): 53% rated it 9 or 10 out of 10, and 47% 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; 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 12.3%, heart failure 11.5%, pneumonia 19.9%, COPD 8.7%, stroke 9.2%. 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 15.9%, heart failure 20.5%, pneumonia 19.4%, COPD 19.3%, hip or knee replacement 5.4%. 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; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 173 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 3% left before being seen.
- 66% 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 0.97 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 1 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 2 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1972.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- It has an inpatient rehabilitation unit of 15 beds, which CMS lists apart as a rehabilitation facility.
- Voluntary non-profit - Private.
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.
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.
| Date | What | Detail |
|---|---|---|
| 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 2 of 5.
- 75% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Penn Highlands Healthcare, Inc. runs it.
- 24 owners or officers are people: Douglas Winner (corporate officer); Jourdan D Strishock (corporate officer); Jourdan D Strishock (managing employee (on the payroll)); Russell E Cameron (corporate officer); Robert W O’leary (corporate director); Trina L Johnson (corporate officer); Edward Yahner (corporate director); Joanne Ryan (corporate director); David Lezzer (corporate director); James E Devlin (corporate director); Carlyn Belczyk (corporate director); Samuel Lewis (corporate director); Richard L Pfingstler (corporate director); Donald E Conrad (corporate director); Scott H Foradora (corporate director); Mark Norman (managing employee (under contract), 0%); Mark Norman (corporate officer, 0%); William H Young (corporate director); Mark Mcginley (corporate director); James B Ryan (corporate director); John S Sutika (corporate director); Brian S Kline (managing employee (under contract), 0%); Brian S Kline (corporate officer, 0%); Steven M Fontaine (corporate officer).
- CMS’s Provider of Services file records 3 changes of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
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.
How does it compare nearby?
- Of the 4 hospitals CMS lists in Washington County, 3 have an overall star rating from CMS: 1 rated 4 of 5, 1 rated 3 of 5, 1 rated 1 of 5.
- CMS rates this one 1 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| The Washington Hospital | 4 |
| Canonsburg General Hospital | 3 |
| Advanced Surgical Hospital | Not given |
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
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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.
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.