Initial Comments:
This report is the result of a State licensure survey conducted on November 9, 2023, at York Adams Pain Specialists. 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:
563.12 (2) LICENSURE
Form and Content of Record
Name - Component - 00
563.12 Form and content of record
The ASF shall maintain a separate medical
record for each patient. Each record shall be accurate, legible and
promptly completed. Patient medicals shall be constructed to stand alone and be easily identified as ASF records. Medical records must include at least the following:
(2) Pertinent medical history and results of physical examination
Observations:
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that 2 out of 10 medical records had documented physical examinations prior to receiving services (MR1, and MR2).
Findings include:
On November 6, 2023, at approximately 12:30 PM, a review of facility policy titled "Pre-Procedure Phase" with a revision date of September 2014, revealed "... all patients will have a recent history and physical examination (no more than 30 days prior), either by their primary care physician or by the ASF physician, prior to any procedure ..."
Review of medical records conducted on November 6, 2023, at approximately 11:00 AM revealed MR1 did not have a physical examination documented prior to the operative procedure.
Review of MR2 on November 6, 2023, revealed that MR2 did not have a physical examination documented prior to the operative procedure.
An interview with EMP1 on November 6, 2023, at approximately 12:30 PM confirmed the above findings that MR1 and MR2 did not have documentation of a physical exam being completed.
Plan of Correction:In order to ensure appropriate and complete documentation of history and physical exam on all charts, our medical record chart review lists were updated on 11/16/23 to clarify all required elements. A review of our H & P policy, all required elements of H & P's and our updated forms will be completed by all of the staff and provider by December 15th, 2023. One month following completion of education, a focused chart review of 10 random charts will be completed by the Director of Nursing to ensure compliance. Our medical records reviewer will continue to review 100% of all charts.
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