QA Investigation Results

Pennsylvania Department of Health
CHAMBERSBURG ENDOSCOPY CENTER, LLC
Health Inspection Results
CHAMBERSBURG ENDOSCOPY CENTER, LLC
Health Inspection Results For:


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Initial Comments:

This report is the result of a full Medicare recertification survey conducted on December 10, 2018, at Chambersburg Endoscopy Center, LLC. 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:




416.42(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 documents, medical records (MR), and staff interview (EMP), it was determined Chambersburg Endoscopy Center failed to ensure that the practitioner performed an examination of the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed for nine of nine medical records reviewed (MR2-MR10), and failed to adopt a policy consistent with the regulations that a practitioner perform an examination of the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed.

Findings include:

Review of "Chambersburg Endoscopy Center, LLC, Description of Services/Standards of Care", dated November 2018, revealed "Preprocedure Care. A. A history and physical examination is completed on the day of the patient's procedure within the Provation Multicare system. 1. Staff review and revise medical content within Provations for accuracy during pre-calls and/or during the pre-procedure process. 2. The patient's preanesthesia assessment will be completed by the anesthesia personnel. This assessment will include auscultation of the chest and lungs, cardiac rhythm, and an ASA level which will serve as the physical assessment of the history and physical. 3. A practitioner shall review the content of the patient's medical record and physical assessment within Provations, immediately prior to the procedure to evaluate the risk of anesthesia and of the procedure to be performed ... ."

1. Review of MR2-MR10, revealed no documentation that a physician performed a physical examination of the patient to evaluate the risk of anesthesia and the procedure to be performed.

2. Interview with EMP1 on December 10, 2018, confirmed the findings.











Plan of Correction:

A physician will examine the patient immediately before surgery to evaluate their current condition, the risk of anesthesia, and of the procedure to be performed. The physician will review the materials from the history and physical assessment, document any changes, complete and document a physical exam, and assign and document an ASA Physical Status classification. The physician will determine if the planned procedure falls within an acceptable range for that patient to have a procedure in an ambulatory surgical center based on the patient's history, current condition, ASA assessment, and the physician's knowledge of the risks of the planned procedure.
To ensure that this assessment is completed an area will be added to the history and physical to document the review. The electronic medical record will be reviewed to ensure that the physician is documenting the ASA assessment and examination.
The policy Description of Services/Standard of Care will be edited by January 14th to reflect the above changes.
Starting on January 21st, 2019 twenty charts per month will be monitored, by the Director of Nursing, to ensure that this assessment is being completed as defined above. This monitoring will continue for 90 days. After the 90-day period routine chart audits will continue to occur based on the quality assurance policy. All findings of the monitoring will be reported to the quality assurance committee by the Director of Nursing.
If non-compliance is noted at any time the provider will be reeducated by the center director.
The Center Director and Medical Director will be responsible for the plan.
The Center Director will forward education to all credentialed providers regarding the requirements by January 14th, 2019.
Implementation of the plan of correction will take effect on January 21st, 2019.



416.52(a)(1) STANDARD
ADMISSION ASSESSMENT

Name - Component - 00
Not more than 30 days before the date of the scheduled surgery, each patient must have a comprehensive medical history and physical assessment completed by a physician (as defined in section 1861(r) of the Act) or other qualified practitioner in accordance with applicable State health and safety laws, standards or practice, and ASC policy.



Observations:

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determinedChambersburg Endoscopy Center failed to ensure that a physician performed a comprehensive history and physical assessment of the patient for nine of nine medical records reviewed (MR2-MR10), and failed to adopt a policy consistent with the regulations that a a physician perform a comprehensive history and physical examination of the patient.

Findings include:

Review of "Chambersburg Endoscopy Center, LLC, Description of Services/Standards of Care", dated November 2018, revealed "Preprocedure Care. A. A history and physical examination is completed on the day of the patient's procedure within the Provation Multicare system. 1. Staff review and revise medical content within Provations for accuracy during pre-calls and/or during the pre-procedure process. 2. The patient's preanesthesia assessment will be completed by the anesthesia personnel. This assessment will include auscultation of the chest and lungs, cardiac rhythm, and an ASA level which will serve as the physical assessment of the history and physical. 3. A practitioner shall review the content of the patient's medical record and physical assessment within Provations, immediately prior to the procedure to evaluate the risk of anesthesia and of the procedure to be performed ... ."

1. Review of MR2-MR10, revealed no documentation that a physician performed a comprehensive history and physical of the patient prior to the procedure.

2. Interview with EMP1 on December 10, 2018, confirmed the findings.










Plan of Correction:

Each patient has a comprehensive medical history and physical assessment completed prior to the date of their procedure. This history and physical will be obtained from the gastroenterology office and attached to the patient's chart prior to their procedure. On the day of the procedure the physician will review medications, allergies, health history, and complete a physical examination to evaluate for any changes in the patient's status since the history and physical. The physician will document on the history and physical that the information was reviewed with no changes. This statement will be dated and signed by the physician.
Clerical personnel will place the history and physical on the chart during chart preparation with an area for the physician to document their reevaluation. Admission personnel will ensure that the history and physical is on the chart during the preprocedural process and that there is an area to document. Room technicians will verify that the history and physical is present and that the documentation area has been completed prior to the time out.
The policy Description of Services/Standard of Care will be edited by January 14th to reflect the above changes.
Starting on January 21st, 2019 twenty charts per month will be monitored, by the Director of Nursing, to ensure that the history and physical is being scanned and that the reevaluation is completed by consulting the Provation Multicare system (electronic medical record). This monitoring will continue for 90 days. After the 90-day period routine chart audits will continue to occur based on the quality assurance policy. All findings of the monitoring will be reported to the quality assurance committee by the Director of Nursing.
If non-compliance is noted at any time the provider will be reeducated by the center director.
The Center Director and Medical Director will be responsible for the plan.
The Center Director will forward education to all credentialed providers regarding the requirement for the history and physical by January 14th, 2019.



Initial Comments:

This report is the result of a State licensure survey conducted on December 10, 2018, at Chambersburg Endoscopy Center, LLC. 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 documents, medical records (MR), and staff interview (EMP), it was determined Chambersburg Endoscopy Center failed to ensure that the practitioner performed an examination of the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed, failed to ensure that a physician performed a comprehensive history and physical assessment of the patient for nine of nine medical records reviewed (MR2-MR10), and failed to adopt a policy consistent with the regulations that a practitioner perform an examination of the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed and that a a physician perform a comprehensive history and physical examination of the patient.

Findings include:

Review of "Chambersburg Endoscopy Center, LLC, Description of Services/Standards of Care", dated November 2018, revealed "Preprocedure Care. A. A history and physical examination is completed on the day of the patient's procedure within the Provation Multicare system. 1. Staff review and revise medical content within Provations for accuracy during pre-calls and/or during the pre-procedure process. 2. The patient's preanesthesia assessment will be completed by the anesthesia personnel. This assessment will include auscultation of the chest and lungs, cardiac rhythm, and an ASA level which will serve as the physical assessment of the history and physical. 3. A practitioner shall review the content of the patient's medical record and physical assessment within Provations, immediately prior to the procedure to evaluate the risk of anesthesia and of the procedure to be performed ... ."

1. Review of MR2-MR10, revealed no documentation that a physician performed a physical examination of the patient to evaluate the risk of anesthesia and of the procedure to be performed, and revealed no documentation that a physician performed a comprehensive history and physical of the patient prior to the procedure.

2. Interview with EMP1 on December 10, 2018, confirmed the findings.



















Plan of Correction:

A physician will examine the patient immediately before surgery to evaluate their current condition, the risk of anesthesia, and of the procedure to be performed. The physician will review the materials from the history and physical assessment, document any changes, complete a physical exam, and assign an ASA Physical Status classification. The physician will determine if the planned procedure falls within an acceptable range for that patient to have a procedure in an ambulatory surgical center based on the patient's history, current condition, ASA assessment, and the physician's knowledge of the risks of the planned procedure.
To ensure that this assessment is completed an area will be added to the history and physical to document the review. The electronic medical record will be reviewed to ensure that the physician is documenting the ASA assessment and examination.
The policy Description of Services/Standard of Care will be edited by January 14th to reflect the above changes.
Starting on January 21st, 2019 twenty charts per month will be monitored, by the Director of Nursing, to ensure that this assessment is being completed as defined above. This monitoring will continue for 90 days. After the 90-day period routine chart audits will continue to occur based on the quality assurance policy. All findings of the monitoring will be reported to the quality assurance committee by the Director of Nursing.
If non-compliance is noted at any time the provider will be reeducated by the center director.
The Center Director and Medical Director will be responsible for the plan.
The Center Director will forward education to all credentialed providers regarding the requirements by January 14th, 2019.
Implementation of the plan of correction will take effect on January 21st, 2019.

Each patient has a comprehensive medical history and physical assessment completed prior to the date of their procedure. This history and physical will be obtained from the gastroenterology office and attached to the patient's chart prior to their procedure. On the day of the procedure the physician will review medications, allergies, health history, and complete a physical examination to evaluate for any changes in the patient's status since the history and physical. The physician will document on the history and physical that the information was reviewed with no changes. This statement will be dated and signed by the physician.
Clerical personnel will place the history and physical on the chart during chart preparation with an area for the physician to document their reevaluation. Admission personnel will ensure that the history and physical is on the chart during the preprocedural process and that there is an area to document. Room technicians will verify that the history and physical is present and that the documentation area has been completed prior to the time out.
The policy Description of Services/Standard of Care will be edited by January 14th to reflect the above changes.
Starting on January 21st, 2019 twenty charts per month will be monitored, by the Director of Nursing, to ensure that the history and physical is being scanned and that the reevaluation is completed by consulting the Provation Multicare system (electronic medical record). This monitoring will continue for 90 days. After the 90-day period routine chart audits will continue to occur based on the quality assurance policy. All findings of the monitoring will be reported to the quality assurance committee by the Director of Nursing.
If non-compliance is noted at any time the provider will be reeducated by the center director.
The Center Director and Medical Director will be responsible for the plan.
The Center Director will forward education to all credentialed providers regarding the requirement for the history and physical by January 14th, 2019.