QA Investigation Results

Pennsylvania Department of Health
ENDOSCOPY CENTER OF CENTRAL PENNSYLVANIA, LLC
Health Inspection Results
ENDOSCOPY CENTER OF CENTRAL PENNSYLVANIA, LLC
Health Inspection Results For:


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Initial Comments:

This report is the result of a full Medicare recertification survey conducted on
August 15, 2018, at Endoscopy Center of Central Pennsylvania. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions of Participation for Ambulatory Surgical Centers.







Plan of Correction:




416.2 STANDARD
DEFINITIONS

Name - Component - 00
As used in this part:
Ambulatory surgical center or ASC means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission. The entity must have an agreement with CMS to participate in Medicare as an ASC, and must meet the conditions set forth in subparts B and C of this part.The ambulatory surgical center must comply with state licensure requirements.


Observations:

Based on observation and interview with staff (EMP), it was determined that the facility failed to comply with the distinct entity requirements during their hours of operation.

Findings include:

Observation on August 15, 2018, at 8:30 AM, of the facility, revealed that in the building that was used by the ambulatory surgical center (ASF) and a physician practice, the waiting area and the reception/office area were shared by patients of the ASF and the practice. Interview with EMP1 on August 15, 2018 revealed that the hours of operation for both providers was 6:45 am to 2:45 pm.

Interview with EMP1 confirmed that the waiting and reception/office areas were shared by both sets of patients and the hours of operation for both providers were 6:45 am to 2:45 pm.


























Plan of Correction:

POC being submitted to adhere to compliance of Life Safety Code Standard 416.2

correction: Center has requested a continuing waiver of the CMS regulatory requirements 416.2. This continuing waiver request was e-mailed to Ms. Sheila Osborne , Licensure & Certification Division of Safety Inspection on 08/29/2018.

The hours of operation for the Center are 0645-1445 and the hours of operation for the practice are 0800-1700.

The Endoscopy Center will also meet with Lobar Associates by October 15, 2018 to get a draft design for the upgrading of the waiting room. Endoscopy Center will request that the drawings be completed by November 12, 2018 and be submitted to PA DOH Health Facility review by December 3, 2018. Upon approval by the Governing Board, Endoscopy Center will start the construction to meet the requirements. The projected completion of this construction project is within 6 months of the DOH accepting submitted drawings. At the end of construction, Endoscopy Center will request an Occupancy Inspection to verify completion and approval.

Submitted by:
Victoria L. Farr, RN, CGRN
Center Director




Initial Comments:

This report is the result of a State licensure survey conducted on August 15, 2018, at Endoscopy Center of Central Pennsylvania. 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:




553.3 (1) LICENSURE
Governing Body Responsibilities

Name - Component - 00
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.


Observations:

The facility was found to be non-compliant with the following Federal requirement: ambulatory surgical center or ASC means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission. The entity must have an agreement with CMS to participate in Medicare as an ASC, and must meet the conditions set forth in subparts B and C of this part. The ambulatory surgical center must comply with state licensure requirements.

Based on observation and interview with staff (EMP), it was determined that the facility failed to comply with the distinct entity requirements during their hours of operation.

Findings include:

Observation on August 15, 2018, at 8:30 AM, of the facility, revealed that in the building that was used by the ambulatory surgical center (ASF) and a physician practice, the waiting area and the reception/office area were shared by patients of the ASF and the practice. Interview with EMP1 on August 15, 2018 revealed that the hours of operation for both providers was 6:45 am to 2:45 pm.

Interview with EMP1 confirmed that the waiting and reception/office areas were shared by both sets of patients and the hours of operation for both providers were 6:45 am to 2:45 pm.























Plan of Correction:

POC being submitted to adhere to requirement 553.3 (1) of the PaDOH Rules and regulations for Ambulatory Care facilities.

correction: At the time of the survey on 08/15/2018, the Center had a current waiver from CMS. The hours of operation for the Endoscopy Center is 0645-1445 and the hours of operation for the practice is 0800-1700.
The Center submitted a request for a continuance of the current waiver to DSI as was instructed on 08/29/2018.
The requested waiver continuance will not result in any adverse health and safety impact, taking into account the protections currently in place.
The policy of the Center is to adhere to all regulatory requirements and/or waiver that is in currently in place.

The Endoscopy Center will also meet with Lobar Associates by October 15, 2018 to get a draft design for the upgrading of the waiting room. Endoscopy Center will request that the drawings be completed by November 12, 2018 and be submitted to PA DOH Health Facility review by December 3, 2018. The projected completion of this construction project is within 6 months of the DOH accepting submitted drawings. Upon approval by the Governing Board, Endoscopy Center will start the construction to meet the requirements. At the end of construction, Endoscopy Center will request an Occupancy Inspection to verify completion and approval.


Submitted by:
Victoria L. Farr, RN, CGRN
Center Director