Initial Comments:
This report is the result of a full Medicare recertification survey conducted on March 28, 2024, at Mid-Atlantic Gastrointestinal Center. It was determined the facility was in substantial compliance with 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
(1) Immediately before surgery -- (ii) A physician or anesthetist as defined at §410.69(b) of this chapter must examine the patient to evaluate the risk of anesthesia.
Observations:
Based on review of facility documents, medical records (MR), and employee (EMP) interview it was determined the facility anesthesia staff failed to ensure to identify the patient in one of 10 MR reviewed (MR5).
Findings Include:
On March 28, 2024, review of facility policy "Pre-Anesthesia Assessment" effective January 2024, revealed "Policy: Patients receive a pre-anesthesia assessment to evaluate their medical condition and to develop an anesthetic plan. The plan and the patient's medical condition/history is discussed with the patient. Procedure: Pre-Anesthesia Evaluation and preparation includes: Personally interview the patient to: Identify the patient ..."
On March 28, 2024, review of MR5 "Anesthesia Record" dated November 20, 2023, revealed there is no documented evidence the anesthetist checked the patient's identity prior to procedure.
Interview with EMP1 on March 28, 2024, EMP1 confirmed MR5 did not have documentation of patient identification by anesthesia staff.
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Based on review of facility documents, medical records (MR), and employee (EMP) interview it was determined the facility anesthesia staff failed to ensure the anesthesia equipment was checked for readiness and working condition prior to use in one of 10 MR reviewed (MR5).
Findings Include:
On March 28, 2024, review of facility policy "Anesthesia Responsibilities" effective June 2023, revealed "Purpose: To ensure the delivery of safe, high quality anesthesia services by specialty-trained, qualified and credentialed clinicians ... Peri-anesthetic care: Routine checks are conducted by the anesthesia provider prior to every administration of anesthesia to ensure the readiness, availability, cleanliness (sterility when required), and working condition of all equipment used in the administration of anesthetic agents ..."
On March 28, 2024, review of MR5 "Anesthesia Record" dated November 20, 2023, revealed there was no evidence the anesthetist checked the anesthesia equipment for readiness and working condition prior to use.
Interview with EMP1 on March 28, 2024, EMP1 confirmed MR5 did not have documentation the anesthetist checked anesthesia equipment for readiness and working condition prior to use.
Plan of Correction:SYSTEMIC CHANGES
The Chief CRNA will complete a review to of policies "Pre-Anesthesia Assessment" and "Anesthesia Responsibilities" for education about proper documentation of patient ID verification and anesthesia equipment is being checked to CRNA staff by 4/19/2024. Any PRN CRNA staff will review the policies on next scheduled day at the Center, to be completed by 4/26/2024.
MONITORING AND SUSTAINING THE PLAN
The CA or DON will audit 10 random charts per day for 30 days verifying proper documentation of patient ID verification and anesthesia equipment is checked until 100% compliant. Audits will begin 4/29/2024. The monthly medical record audit will be used going forward to capture compliance and identify need for re-education.
RESPONSIBLE PARTY AND REPORTING
The CA is responsible to implement the changes identified in this POC.
The CA will provide results of this survey, the corrective actions, and results from monitoring to the Quality Assurance Improvement Committee quarterly for review and recommendations.
Recommendations will be submitted to the Governing Board for review and approval.
416.51(a) STANDARD
SANITARY ENVIRONMENT
Name - Component - 00
The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.
Observations:
Based on review of facility documents, observation, and employee (EMP) interview it was determined the facility failed to ensure a sanitary environment was maintained by adhering to professionally acceptable standards of practice.
Findings include:
On March 28, 2024, review of facility policy "Hand Hygiene (4)" effective January 2024, revealed "Policy: Center personnel follow the hand-hygiene techniques as outlined by the Centers for Disease Control and this policy. Purpose: To prevent the transmission of bacteria, germs and infections Procedure: Always use products according to product manufacturer's instructions to use. Indications for Handwashing (this is not an all-inclusive list): Handwashing may also be used for routinely decontaminating hands in the following clinical situations: Before having direct contact with patients; Before donning gloves; After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient); After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled; When moving from a contaminated body site to a clean body site during patient care; After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; After removing gloves ..."
Observation on March 28, 2024, in Bay 11, EMP2 did not perform hand hygiene before having direct contact with patient.
Observation on March 28, 2024, in Procedure room 4, EMP3 did not perform hand hygiene after contact with patient's intact skin, after removing gloves and prior to donning new gloves x 2 during procedure. In addition, EMP2 did not perform hand hygiene after contact with patient, contact with inanimate objects and removing gloves when procedure was complete.
Interview with EMP1 on March 28, 2024, EMP1 confirmed EMP2 and EMP3 did not follow facility policy.
Plan of Correction:SYSTEMIC CHANGES
The CA or designee will review the policy "Hand Hygiene (4) and provide education on when to wash/sanitize hands with staff by 4/12/2024, and with CRNA staff by 4/26/2024. Posters identifying the 5 areas to use hand hygiene will be posted for reminders to follow Hand Hygiene practices.
MONITORING AND SUSTAINING THE PLAN
The CA or designee will complete 5 random hand hygiene audits per day for 30 days verifying proper hand hygiene is performed until 100% compliant. Re-education will be provided when needed. Audits will begin 4/29/24. Random monthly hand hygiene audits will be used going forward to capture compliance and identify need for re-education.
RESPONSIBLE PARTY AND REPORTING
The CA is responsible to implement the changes identified in this POC.
The CA will provide results of this survey, the corrective actions, and results from monitoring to the Quality Assurance Improvement Committee quarterly for review and recommendations.
Recommendations will be submitted to the Governing Board for review and approval.
RE-LICENSURE RESPONSES (STATE)
Initial Comments S 0000
Notification to Center
The Center Administrator (CA) notified the Medical Director and Governing Board (GB) of the preliminary results from the agency visit on 3/28/2024.
Initial Comments:
This report is the result of a State licensure survey conducted on March 28, 2024, at Mid-Atlantic Gastrointestinal 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:
555.33 (d)(1) LICENSURE
Anesthesia Policies and Procedures
Name - Component - 00
555.33 Anesthesia policies and procedures
(d) Anesthesia procedures shall provide at least the following:
(1) A patient requiring anesthesia shall have a pre-anesthesia evaluation by a practitioner, with appropriate documentation of pertinent information regarding the choice of anesthesia.
Observations:
Based on review of facility documents, medical records (MR), and employee (EMP) interview it was determined the facility anesthesia staff failed to ensure to identify the patient in one of 10 MR reviewed (MR5).
Findings Include:
On March 28, 2024, review of facility policy "Pre-Anesthesia Assessment" effective January 2024, revealed "Policy: Patients receive a pre-anesthesia assessment to evaluate their medical condition and to develop an anesthetic plan. The plan and the patient's medical condition/history is discussed with the patient. Procedure: Pre-Anesthesia Evaluation and preparation includes: Personally interview the patient to: Identify the patient ..."
On March 28, 2024, review of MR5 "Anesthesia Record" dated November 20, 2023, revealed there is no documented evidence the anesthetist checked the patient's identity prior to procedure.
Interview with EMP1 on March 28, 2024, EMP1 confirmed MR5 did not have documentation of patient identification by anesthesia staff.
Plan of Correction:S 5559
555.33 (d)(1) Anesthesia Policies and Procedures
SYSTEMIC CHANGES
The Chief CRNA will complete a review to of policies "Pre-Anesthesia Assessment" and "Anesthesia Responsibilities" for education about proper documentation of patient ID verification and anesthesia equipment is being checked to CRNA staff by 4/19/2024. Any PRN CRNA staff will review the policies on next scheduled day at the Center, to be completed by 4/26/2024.
MONITORING AND SUSTAINING THE PLAN
The CA or DON will audit 10 random charts per day for 30 days verifying proper documentation of patient ID verification and anesthesia equipment is checked until 100% compliant. Audits will begin 4/29/24 The monthly medical record audit will be used going forward to capture compliance and identify need for re-education.
RESPONSIBLE PARTY AND REPORTING
The CA is responsible to implement the changes identified in this POC.
The CA will provide results of this survey, the corrective actions, and results from monitoring to the Quality Assurance Improvement Committee quarterly for review and recommendations.
Recommendations will be submitted to the Governing Board for review and approval.
555.33 (d)(3) LICENSURE
Anesthesia Policies and Procedures
Name - Component - 00
555.33 Anesthesia policies and procedures
(d) Anesthesia procedures shall provide at least the following:
(3) Prior to beginning the administration of anesthesia, the anesthetist shall check equipment to be used in administration of anesthetic agents. An anesthetic gas machine in anesthetising areas shall have a pin-index system.
Observations:
Based on review of facility documents, medical records (MR), and employee (EMP) interview it was determined the facility anesthesia staff failed to ensure the anesthesia equipment was checked for readiness and working condition prior to use in one of 10 MR reviewed (MR5).
Findings Include:
On March 28, 2024, review of facility policy "Anesthesia Responsibilities" effective June 2023, revealed "Purpose: To ensure the delivery of safe, high quality anesthesia services by specialty-trained, qualified and credentialed clinicians ... Peri-anesthetic care: Routine checks are conducted by the anesthesia provider prior to every administration of anesthesia to ensure the readiness, availability, cleanliness (sterility when required), and working condition of all equipment used in the administration of anesthetic agents ..."
On March 28, 2024, review of MR5 "Anesthesia Record" dated November 20, 2023, revealed there was no evidence the anesthetist checked the anesthesia equipment for readiness and working condition prior to use.
Interview with EMP1 on March 28, 2024, EMP1 confirmed MR5 did not have documentation the anesthetist checked anesthesia equipment for readiness and working condition prior to use.
Plan of Correction:S 5561
555.33 Anesthesia Policies and Procedures
SYSTEMIC CHANGES
The Chief CRNA will complete a review to of policies "Pre-Anesthesia Assessment" and "Anesthesia Responsibilities" for education about proper documentation of patient ID verification and anesthesia equipment is being checked to CRNA staff by 4/19/2024. Any PRN CRNA staff will review the policies on next scheduled day at the Center, to be completed by 4/26/2024.
MONITORING AND SUSTAINING THE PLAN
The CA or DON will audit 10 random charts per day for 30 days verifying proper documentation of patient ID verification and anesthesia equipment is checked until 100% compliant. Audits will begin 4/29/24 The monthly medical record audit will be used going forward to capture compliance and identify need for re-education.
RESPONSIBLE PARTY AND REPORTING
The CA is responsible to implement the changes identified in this POC.
The CA will provide results of this survey, the corrective actions, and results from monitoring to the Quality Assurance Improvement Committee quarterly for review and recommendations.
Recommendations will be submitted to the Governing Board for review and approval.
567.1 LICENSURE
Principle
Name - Component - 00
567.1 Principle
The ASF shall have a sanitary environment, properly constructed,
equipped and maintained to protect surgical patients and ASF personnel from
cross-infection and to protect the health and safety of patients.
Observations:
Based on review of facility documents, observation, and employee (EMP) interview it was determined the facility failed to ensure a sanitary environment was maintained by adhering to professionally acceptable standards of practice.
Findings include:
On March 28, 2024, review of facility policy "Hand Hygiene (4)" effective January 2024, revealed "Policy: Center personnel follow the hand-hygiene techniques as outlined by the Centers for Disease Control and this policy. Purpose: To prevent the transmission of bacteria, germs and infections Procedure: Always use products according to product manufacturer's instructions to use. Indications for Handwashing (this is not an all-inclusive list): Handwashing may also be used for routinely decontaminating hands in the following clinical situations: Before having direct contact with patients; Before donning gloves; After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient); After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled; When moving from a contaminated body site to a clean body site during patient care; After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; After removing gloves ..."
Observation on March 28, 2024, in Bay 11, EMP2 did not perform hand hygiene before having direct contact with patient.
Observation on March 28, 2024, in Procedure room 4, EMP3 did not perform hand hygiene after contact with patient's intact skin, after removing gloves and prior to donning new gloves x 2 during procedure. In addition, EMP2 did not perform hand hygiene after contact with patient, contact with inanimate objects and removing gloves when procedure was complete.
Interview with EMP1 on March 28, 2024, EMP1 confirmed EMP2 and EMP3 did not follow facility policy.
Plan of Correction:S 6701
571.1 Principle
SYSTEMIC CHANGES
The CA or designee will review the policy "Hand Hygiene (4) and provide education on when to wash/sanitize hands with staff by 4/12/2024, and with CRNA staff by 4/26/2024. Posters identifying the 5 areas to use hand hygiene will be posted for reminders to follow Hand Hygiene practices.
MONITORING AND SUSTAINING THE PLAN
The CA or designee will complete 5 random hand hygiene audits per day for 30 days verifying proper hand hygiene is performed until 100% compliant. Re-education will be provided when needed. Audits will begin 4/29/24. Random monthly hand hygiene audits will be used going forward to capture compliance and identify need for re-education.
RESPONSIBLE PARTY AND REPORTING
The CA is responsible to implement the changes identified in this POC.
The CA will provide results of this survey, the corrective actions, and results from monitoring to the Quality Assurance Improvement Committee quarterly for review and recommendations.
Recommendations will be submitted to the Governing Board for review and approval.
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