QA Investigation Results

Pennsylvania Department of Health
DERMATOLOGIC SURGICENTER - DREXEL HILL
Health Inspection Results
DERMATOLOGIC SURGICENTER - DREXEL HILL
Health Inspection Results For:


There are  19 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

This report is the result of a full Medicare recertification survey conducted on April 5, 2018, at the Dermatologic SurgiCenter, Drexel Hill. It was determined the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions for Coverage for Ambulatory Surgical Centers.









Plan of Correction:




416.42(a)(1) STANDARD
ANESTHETIC RISK AND EVALUATION

Name - Component - 00
A physician must examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed.


Observations:

Based on a review of facility policy, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure a practitioner examined the patient immediately before surgery to evaluate the risk of the procedure to be performed for three of 15 medical records reviewed (MR2, MR3 and MR4).

Findings include:

A review on April 5, 2018, of the "Dermatologic SurgiCenter By-Laws" dated March 2018 revealed " 2. Medical Records... b. A full Dermatologic evaluation and when indicated, a complete physical by the referring physician must be recorded within 24 hours of admission. This report shall reflect a comprehensive current Dermatologic assessment. If a complete physical examination has been performed within 7 days prior to the admission, such as in a referring physician's office, a durable, legible, copy of this report may be used in the patient's facility medical record, provided there has been no change subsequent to the original examination of [sic] the changes have been recorded at the time of admission. The recorded physical examination must be authenticated by the examining physician."

A review on April 5, 2018, of the Dermatologic SurgicCenter By-Laws" dated March 2018 revealed "... . Article XIII... . b. A full-dermatologic evaluation and when indicated, a complete physical by the referring physician must be recorded within 24 hours of admission. The report shall reflect a comprehensive current dermatologic assessment... . The recorded physical examination must be authenticated by the examining physician... . The medical record shall document a current appropriate physical examination prior to the performance of surgery.


A review on April 5, 2018, of MR2, admission date October 23, 2017, revealed no evidence of documentation that a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed. Further review revealed no evidence of documentation that a physical examination had been completed prior to the performance of the surgical procedure.

A review on April 5, 2018, of MR3, admission date November 27, 2017, revealed no evidence of documentation that a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed. Further review revealed no evidence of documentation that a physical examination had been completed prior to the performance of the surgical procedure.


A review on April 5, 2018, of MR4, admission date December 5, 2017, revealed no evidence of documentation that a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed. Further review revealed no evidence of documentation that a physical examination had been completed prior to the performance of the surgical procedure.

An interview conducted on April 5, 2018, at 2:55PM with EMP1, EMP2 and EMP3 confirmed that there was no documentation in MR2, MR3 and MR4 that a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed. Further interview confirmed no evidence of documentation that a physical examination had been completed prior to the performance of the surgical procedures for MR2, MR3 and MR4.


















Plan of Correction:

An inservice was conducted with the physician staff reviewing the By-Laws and the importance of documentation completion in regards to patient examination (history and physical) prior to surgical procedures. (Completion date: 5/18/18)

An inservice was conducted with all nursing personnel with emphasis on the importance of documentation completion. Verbal understanding of the necessity to check chart for completion before sending to secretary for operative report transcription was accomplished. (Completion date: 5/18/18)

An inservice was held with the secretarial staff to emphasize the necessity to double check chart documentation completion prior to filing chart. (Completion date: 5/18/18)

Intra-operative record will be revised to include documentation that the practitioner examined the patient immediately before surgery to evaluate risk of anesthesia and of the procedure to be performed. An inservice will be held with the physician, nursing, and secretarial staff regarding the change made to the intra-op record to include documentation that the practitioner shall examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The inservice will be completed by 6/11/18 and the revised form will be used from 6/11/18 on. This change will be shared with the Patient Safety Committee, Quality Assurance Committee, and reported to the Governing Body at the next quarterly meeting (7/2018).

A revision was done to the physician internal peer review form. An addition was made to include checking the charts for documentation of the history and physical form. (Completion date: 4/2018).

The physician staff will increase their internal peer review to 5 charts monthly per physician on each physician for a period of 6 months. (This is an increase from 5 charts bi-annually.)

A 100% compliance rate is the expected outcome of this review. (Completion date: 10/2018).

The nursing monthly chart review form was revised to include "H & P completed by physician prior to surgery." (Completion date: 5/2018).

The results of all chart reviews will be shared with the Patient Safety Committee, Quality Assurance Committee and reported to the Governing Body quarterly. (Completion date: 10/2018).



Initial Comments:

This report is the result of a State licensure survey conducted on April 5, 2018, at Dermatologic SurgiCenter, Drexel Hill. 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:




555.22 (a)(1-2) LICENSURE
Surgical Services - Preoperative Care

Name - Component - 00
555.22 Pre-operative Care

(a) Pertinent medical histories and physical examinations, and supplemental information regarding drug sensitivities documented day of surgery or one of the following:
(1) If medical evaluation, examination and referral are made from a private practitioner's office, hospital or clinic, pertinent records thereof shall be available and made part of the clinical record at the time the patient is registered and admitted tot he ASF. This information is considered valid no more than 30 days prior to the date of surgery.
(2) A practitioner shall examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The information shall be clearly documented in the medical record.



Observations:


Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that Dermatologic SurgiCenter-Drexel Hill failed to ensure that patients received a physical examination completed by a physician for three of 15 medical records reviewed (MR2, MR3 and MR4).

Findings include:

A review on April 5, 2018, of the "Dermatologic SurgiCenter By-Laws" dated March 2018 revealed "2. Medical Records... b. A full Dermatologic evaluation and when indicated, a complete physical by the referring physician must be recorded within 24 hours of admission. This report shall reflect a comprehensive current Dermatologic assessment. If a complete physical examination has been performed within 7 days prior to the admission, such as in a referring physician's office, a durable, legible, copy of this report may be used in the patient's facility medical record, provided there has been no change subsequent to the original examination of [sic] the changes have been recorded at the time of admission. The recorded physical examination must be authenticated by the examining physician."

A review on April 5, 2018, of MR2, admitted on October 23, 2017, revealed no evidence of documentation of a physical examination completed by a physician.

A review on April 5, 2018, of MR3, admitted on November 27, 2017, revealed no evidence of documentation of a physical examination completed by a physician.

A review on April 5, 2018, of MR4, admitted on December 5, 2017, revealed no evidence of documentation of a physical examination completed by a physician.

An interview conducted on April 5, 2018, at 2:55PM with EMP1, EMP2 and EMP3 confirmed MR2, MR3, and MR4 did not contain evidence of documentation that a physical examination had been completed by a physician for these patients.

_______________________________

Based on a review of facility policy, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure a practitioner examined the patient immediately before surgery to evaluate the risk of the procedure to be performed for three of 15 medical records reviewed (MR2, MR3 and MR4).

Findings include:

A review on April 5, 2018, of the "Dermatologic SurgiCenter By-Laws" dated March 2018 revealed " 2. Medical Records... b. A full Dermatologic evaluation and when indicated, a complete physical by the referring physician must be recorded within 24 hours of admission. This report shall reflect a comprehensive current Dermatologic assessment. If a complete physical examination has been performed within 7 days prior to the admission, such as in a referring physician's office, a durable, legible, copy of this report may be used in the patient's facility medical record, provided there has been no change subsequent to the original examination of [sic] the changes have been recorded at the time of admission. The recorded physical examination must be authenticated by the examining physician."

A review on April 5, 2018, of the Dermatologic SurgicCenter By-Laws" dated March 2018 revealed "... . Article XIII... . b. A full-dermatologic evaluation and when indicated, a complete physical by the referring physician must be recorded within 24 hours of admission. The report shall reflect a comprehensive current dermatologic assessment... . The recorded physical examination must be authenticated by the examining physician... . The medical record shall document a current appropriate physical examination prior to the performance of surgery.


A review on April 5, 2018, of MR2, admission date October 23, 2017, revealed no evidence of documentation that a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed. Further review revealed no evidence of documentation that a physical examination had been completed prior to the performance of the surgical procedure.

A review on April 5, 2018, of MR3, admission date November 27, 2017, revealed no evidence of documentation that a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed. Further review revealed no evidence of documentation that a physical examination had been completed prior to the performance of the surgical procedure.


A review on April 5, 2018, of MR4, admission date December 5, 2017, revealed no evidence of documentation that a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed. Further review revealed no evidence of documentation that a physical examination had been completed prior to the performance of the surgical procedure.


An interview conducted on April 5, 2018, at 2:55PM with EMP1, EMP2 and EMP3 confirmed that there was no documentation in MR2, MR3 and MR4 that a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed. Further interview confirmed no evidence of documentation that a physical examination had been completed prior to the performance of the surgical procedures for MR2, MR3 and MR4.





































Plan of Correction:

An inservice was conducted with the physician staff reviewing the By-Laws and the importance of documentation completion in regards to patient examination (history and physical) prior to surgical procedures. (Completion date: 5/18/18)

An inservice was conducted with all nursing personnel with emphasis on the importance of documentation completion. Verbal understanding of the necessity to check chart for completion before sending to secretary for operative report transcription was accomplished. (Completion date: 5/18/18)

An inservice was held with the secretarial staff to emphasize the necessity to double check chart documentation completion prior to filing chart. (Completion date: 5/18/18)

Intra-operative record will be revised to include documentation that the practitioner examined the patient immediately before surgery to evaluate risk of anesthesia and of the procedure to be performed. An inservice will be held with the physician, nursing, and secretarial staff regarding the change made to the intra-op record to include documentation that the practitioner shall examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The inservice will be completed by 6/11/18 and the revised form will be used from 6/11/18 on. This change will be shared with the Patient Safety Committee, Quality Assurance Committee, and reported to the Governing Body at the next quarterly meeting (7/2018).

A revision was done to the physician internal peer review form. An addition was made to include checking the charts for documentation of the history and physical form. (Completion date: 4/2018).

The physician staff will increase their internal peer review to 5 charts monthly per physician on each physician for a period of 6 months. (This is an increase from 5 charts bi-annually.)

A 100% compliance rate is the expected outcome of this review. (Completion date: 10/2018).

The nursing monthly chart review form was revised to include "H & P completed by physician prior to surgery." (Completion date: 5/2018).

The results of all chart reviews will be shared with the Patient Safety Committee, Quality Assurance Committee and reported to the Governing Body quarterly. (Completion date: 10/2018).