This report is the result of a State licensure survey conducted on March 19, 2018, at Afp Surgery 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:
553.31 (a) LICENSURE
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A full time person in charge shall be appointed who has authority and responsibility for the operation of the ASF at all times. Qualifications, authority, responsibilities and duties of the person in charge shall be defined in a written statement adopted by the governing body.
Based on a review of facility documents, facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that a full-time person was appointed who had authority and responsibility for the operation of the Ambulatory Surgical Center (ASC) at all times for four of ten medical records reviewed (MR3, MR4, MR5 and MR6).
A review on March 19, 2018, of facility "Policy: 206 Administrative Responsibilities" effective date April 28, 2016, revealed, "6. The Medical Director is responsible at all times for the clinical and administrative activities of the Center. ... . 12. The Medical Director is the "person in charge" of the Center. ... ."
A review on March 19, 2018, of a letter dated March 1, 2017, to Division of Acute and Ambulatory Care Director revealed, "Please note the change in Administrator to AFP Surgery Center. Dr. Craig T. McHugh D.P.M. FACFAS will assume the responsibilities of administrator. ... ."
A review on March 19, 2018, of an Exception response letter from the Division of Acute and Ambulatory Care to EMP1 dated January 3, 2018, revealed, "The Department of Health is in receipt of your request for an exception to 28 Pa. Code 553.31(a), related to Administrative Responsibilities. ... . Based on the narrative submitted, your request was denied. If you wish to request a reconsideration of a denial or revocation, you must write to the Division Director within 30 days after service of the adverse notification. ... . Should you require further information or have questions, please contact the Division of Acute and Ambulatory Care... ."
A review of MR3 and MR4 revealed the patients had procedures performed on October 18, 2017. Further review revealed documentation that EMP1 had performed the surgery for MR3 and MR4 on October 18, 2017.
A review of MR5 revealed the patient had a procedure performed on October 25, 2017. Further review revealed documentation that EMP1 had performed the surgery on the patient on October 25, 2017.
A review of MR6 revealed the patient had a procedure performed on November 15, 2017. Further review revealed documentation that EMP1 had performed the surgery on the patient on November 15, 2017.
An interview conducted on March 19, 2018, at 3:00 PM with EMP1 confirmed that EMP1 was appointed as the Administrator on March 2, 2017, and functioned as the Administrator and surgeon since that date. Further interview confirmed that EMP1 had performed surgery on patients MR3, MR4, MR5 and MR6 since appointment as the Administrator. In addition, EMP1 confirmed understanding the Exception Denial letter to mean that the exception request was not needed and therefore, EMP1 could continue as the Administrator.
Plan of Correction:
If the exception filed for regulation 553.31a is denied with the Department of Health, the plan would consist of the Medical Director and the Administrator changing roles. When the Administrator is dealing with direct patient care, then the Medical Director will assume the role of the Administrator granted they are not involved in patient care. The alternative plan would be if the Administrator is not available to oversee the administrative duties nor is the Medical Director, then the Center's Human Resources Manager will assume this role as Administrator in the interim. The Governing Body met and approved the Administrative coverage plan. Policy 206, Administrative Responsibilities ,was revised with the coverage of duties by the Administrator and approved by the Governing Body. Job descriptions included the responsibilities for coverage by the Administrator were established and approved by the Governing Body. The Human Resources Manager will be educated on the administrative responsibilities policy. The job descriptions will be signed and placed in their personnel files. The Governing Body approved the document designed (in log form) that will document the administrative coverage that will include date, time, month, year and Administrator coverage. The Medical Director is responsible for the Plan of Correction