QA Investigation Results

Pennsylvania Department of Health
ABINGTON MEMORIAL HOSPITAL-ASPLUNDH SURGERY CENTER
Health Inspection Results
ABINGTON MEMORIAL HOSPITAL-ASPLUNDH SURGERY CENTER
Health Inspection Results For:


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Initial Comments:

This report is the result of a full State Licensure survey conducted on February 28, 2019 and completed offsite March 6, 2019, at the Abington Meomorial Hospital Asplundh surgery Center. It was determined that 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:




553.1 Principle LICENSURE
CHAPTER 553 - Ownership,Goverance,Management

Name - Component - 00
553.1 PRINCIPLE

There shall be an organized governing body or designated person vested with
ownership who shall assume the full legal authority and responsibility for the conduct of the ASF.



Observations:


Based on observation, review of facility documents and interview with staff (EMP) it was determined the Governing Body failed to assume full responsibility for the conduct of the Abington Memorial Hospital-Asplundh Surgery Center. This is evidenced by (033A) failed to provide education to facility staff for the Patient Safety Plan and ACT 70, (033F) failed to ensure policies and procedures were specific to the surgery center, (033S) failed to ensure contract agreements were obtained for services and failed to conducted quality review of contracted services, (034B) failed to conduct an annual governing Body Meeting specific to the surgery center, (3250) failed to ensure patients met discharge criteria prior to discharge, (331B) failed to ensure discharge criteria was reviewed for patients receiving local anesthesia, (53B0) failed to ensure practioner ' s were credentialed for the surgery center, (552A) failed to ensure physician exams were conducted prior to procedures and failed to ensure history and physicals were current, (552C) failed to ensure preoperative instructions were provided, (554G) failed to ensure discharge orders were written, (6903) failed to provide a written disaster plan specific for the surgery center, (6900) failed to ensure fire safety systems were inspected quarterly, (6907) failed to conduct a disaster plan specific for the surgery center.


Findings include:


Review on March 2, 2019, of the facility's "Amended and Restated Bylaws of Abington Hospital" revised November 27, 2018, revealed " Article III, Board Role. 3.2.1 The Board shall have responsibility for overall policy and strategic clinical direction of the Hospital with a focus on performance improvement and patient safety, licensure and accreditation, compliance, disaster planning, recommendation of annual operating and capital budgets, risk management and community relations ..."

Interview on February 28, 2019, at approximately 1:45 PM with EMP1 confirmed the Governing Body is responsible for the surgical center.

Cross reference:

553.3(1) Governing Body Responsibilities
553.3 (6) Governing Body Responsibilities
553.3(13) (i-iv) Governing Body Responsibilities
553.4(b) Other Functions
553.25 (1-6) Discharge Criteria
553.3(b) Administrative Responsibilities
555.3(b) Requirements
555.22 (a)(1-2) Surgical Services Preoperative Care
555.22(c)(1-5) Surgical Services Preoperative Care
555.24 (f)(1-7) Surgical Services Post-Operative
569.3 Policy and Procedures
569.13 Testing Fire Warning Systems
569.14 Internal Disaster and Fire Plans







Plan of Correction:

The Manager Asplundh Surgery Center is responsible for the corrective action and ongoing compliance. The Asplundh Surgery Center develops an independent Governing Body and Medical Executive Committee and establish bylaws and committees to demonstrate full responsibility for oversight of Surgery Center operations. These responsibilities to include the following: an annual governing body meeting specific to surgery center ; credentialing and privileging specific to surgery center; staff education for surgery center Patient Safety Plan and Act 70; policies and procedures specific to surgery center; establishment of discharge policy and procedure to include criteria for discharge and requirement for patients to meet discharge criteria; physician examinations and current history and physicals for surgery center patients; preoperative instructions are provided to patient; a written disaster plan is developed specific to surgery center; and occurrence of annual disaster drill specific to surgery center


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:


Based on review of facility policies and procedures, review of personnel files (PF), and interview with staff (EMP), it was determined that the facility failed to conform to all State laws.

The facility was found to be non-compliant with the following State laws:

Adult Protective Services Act - Enactment Act of October 7, 2010, P.L. 484. No. 70 An Act Providing for protection of abused, neglected, exploited or abandoned adults; establishing a uniform Statewide reporting and investigative system for suspected abuse, neglect, exploitation or abandonment of adults; providing for protective services; and prescribing penalties. Chapter 5 Reporting Suspected Abuse by Employees Section 501. Reporting by employees: "(a) Mandatory reporting to agency. (1) An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse or neglect shall immediately make an oral report to an agency. If applicable, the agency shall advise the employee or administrator of additional reporting requirements that may pertain under subsection (b)".

Based on review of facility policies and procedures, review of personnel files (PF), and interview with staff (EMP), the facility failed to provide documented evidence that facility provided education to staff regarding Act 70 for the mandatory reporting of abused, neglected, exploited or abandoned adults for six (6) of six (6) personnel files reviewed. (PF1, PF2, PF3, PF4, PF5 and PF6). Also, failed to implement a policy related to Act 70.

Findings include:

Request was made on February 28, 2019 to EMP1 and EMP2 for a policy related to Act 70 mandatory reporting requirements. None provided.

Review on February 28, 2019, of PF1 revealed no documented evidence of staff training on Act 70 that included abuse, neglected, exploited or abandoned adults.

Review on February 28, 2019, of PF2 revealed no documented evidence of staff training on Act 70 that included abuse, neglected, exploited or abandoned adults.

Review on February 28, 2019, of PF3 revealed no documented evidence of staff training on Act 70 that included abuse, neglected, exploited or abandoned adults.

Review on February 28, 2019, of PF4 revealed no documented evidence of staff training on Act 70 that included abuse, neglected, exploited or abandoned adults.

Review on February 28, 2019, of PF5 revealed no documented evidence of staff training on Act 70 that included abuse, neglected, exploited or abandoned adults.

Review on February 28, 2019, of PF6 revealed no documented evidence of staff training on Act 70 that included abuse, neglected, exploited or abandoned adults.


Interview on February 28, 2019, with EMP1 and EMP2 at approximately 1:40PM, confirmed no documented evidence of staff education for Act 70 mandatory reporting requirements for PF1, PF2, PF3, PF4, PF5 and PF6.

_____________

Based on review of facility policies and procedures, review of personnel files (PF), and interview with staff (EMP), it was determined that the facility failed to conform to all State laws.

The facility was found to be non-compliant with the following State law:

"The Medical Care Availability and Reduction of Error Act, Act 13 of 2002, Chapter 3, Section 307. Patient safety plans. ... (d) Employee notification.--Upon approval of the patient safety plan, a medical facility shall notify all health care workers of the medical facility of the patient safety plan. Compliance with the patient safety plan shall be required as a condition of employment or credentialing at the medical facility."

As evidenced by:

Based on review of facility policies and procedures, review of personnel files (PF), and interview with staff (EMP), it was determined that the facility failed to provide education to facility staff regarding their patient safety program as required by the Medical Care Availability and Reduction of Error Act, Act 13 of 2002 for seven of seven personnel files reviewed (PF1, PF2, PF3, PF4, PF5, and PF6).

Findings include:

Request was made to EMP1 and EMP2 on February 28, 2019 for documented evidence of staff education related to facility's patient safety program and plan. None provided.

Review on February 28, 2019 of facility's patient safety plan, "... Patient Safety Plan," dated June 2018, revealed, " ... Purpose ... to provide and manitain a safe and effective outpatient surgical care environment for all patients who seek services at the facility. In order to promote this level of care, the ... Surgical Center hereby establishes a Patient Safety Plan, the purpose of which is to identify and respond to patient safety issues and comply with reporting requirements ... ."

Review on February 28, 2019 of PF1, PF2, PF3, PF4, PF5, and PF6, "revealed no documented evidence of staff education related to their patient safety program and the Medical Care Availability and Reduction of Error Act, Act 13 of 2002."

Interview with EMP1 and EMP2 on February 28, 2019 at approximately 2:30 PM confirmed there was no documented evidence of staff education related to their patient safety program and the Medical Care Availability and Reduction of Error Act, Act 13 of 2002.








Plan of Correction:

The Surgery Center Manager is responsible for the corrective action and ongoing compliance.
The Surgery Center Manager completed Act 70 Adult Protective Services Act education of all Surgery Center Staff effective March 31, 2019. To insure education of new employees, Act 70 education was added to the orientation packet checklist. The Surgery Center Manager completed staff education regarding patient safety plan effective April 15, 2019. To insure education of new employees, patient safety program education was added to the orientation packet checklist. Documentation of completion of Act 70 and patient safety plan education was added to departmental employee files.



553.3 (6) LICENSURE
Governing Body Responsibilities

Name - Component - 00
Governing Body responsibilities include:
(6) Adopting policies or procedures necessary for the orderly conduct of the ASF.


Observations:

Based on review of facility policies and procedures and interviews with staff (EMP), it was determined the facility's governing body failed to ensure the policies and procedures were consistent in reflecting the identification of the ambulatory surgery facility (ASF) for the orderly conduct of the ASF.

Findings include:

Request was made to EMP1 on February 28, 2019, for the following policies and procedures of the ASF named,"Abington ... Asplundh Surgery Center:" Medical Staff Bylaws, Pre/Post OP, Biomedical Waste, Regular Waste, Emergency Water Supply, Medical Records, Informed Consent, Advance Directives, Universal Protocol, Language Services, and Employee. Provided policies related to "Abington Memorial Hospital."

Request was made to EMP1 on February 28, 2019, for a Hospital Based Provider Exception. None provided.

Review on February 28, 2019, policies and procedures revealed they were not consistent with the identification of the policies and procedures for the ambulatory surgery center named "Abington ... Asplundh Surgery Center." Further review revealed the names of these policies and procedures were: "... Bylaws of the ... Medical, Dental, and Podiatric Staff," "Advance Directives ... ," Hazardous Waste Management," "Retention of Medical Records," "Patient Information-Access, Uses and Disclosure of PHI," "Informed Consent," "Employee Medical & Dental Benefits," "Employee Discipline Policy," "Universal Blood and Body Fluid Precautions," and "Communication with Persons who are Non-English Speaking ... ." Further review revealed the above policies were related to "Abington Memorial Hospital."

Interview with EMP1 on February 28, 2019, at approximately 2:00 PM confirmed the policies and procedures for the ambulatory surgery facility as named above, are owned by "Abington Memorial Hospital." Policies and procedures were not consistent with the identification of the policies and procedures for the ambulatory surgery center named, "Abington ... Asplundh Surgery Center." Further confirmed facility does not have a Hospital Based Provider Exception.









Plan of Correction:

The Surgery Center Manager is responsible for the corrective action and ongoing compliance. Required clinical policies and procedures specific to Asplundh Surgery Center will be reviewed and revised to be consistently identified as Asplundh Surgery Center policies. Hospital Based Provider Exception will be submitted for consideration at DOH Exceptions Committee meeting in May 2019.
To insure ongoing compliance new and revised clinical policies will be reviewed by the Quality Committee to insure consistent identification.



553.3 (13)(i-iv) LICENSURE
Govern Body Responsibilities

Name - Component - 00
Governing Body responsibilities include:
(13) Approving major contracts or arrangements affecting the medical care provided under its auspices, including, those concerning;
(i) The employment for contractual arrangements with practitioners and others providing direct patient care.
(ii) The provision of all treatment related services including, radiology, medical laboratory, pathology , anesthesia and pharmaceutical services.
(iii) The provision of care by other health care organizations.
(iv) The provision of education to students and post graduate trainees.



Observations:

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to obtain written contracts or written service agreements for services provided at the surgery center and failed to ensure services provided were reviewed for quality.

Findings include:


Review on March 2, 2019, of the facility's "Amended and Restated Bylaws of Abington Hospital" revised November 27, 2018, revealed "Article III, Board Role. 3.2.1 The Board shall have responsibility for overall policy and strategic clinical direction of the Hospital with a focus on performance improvement and patient safety, licensure and accreditation, compliance, disaster planning, recommendation of annual operating and capital budgets, risk management and community relations ..."


A request was made on February 25, 2019, to EMP1 for the written service agreement for the facility's laboratory and pathology services. None provided.


Interview on February 25, 2019 with EMP1 confirmed the facility did not have a written contract or written service agreement for laboratory services or pathology services.

_____________

Based on interview with staff (EMP1), it was determined the facility failed to ensure quality review was conducted on services provided at the surgery center through contracts or written service agreements.

Findings include:

Review of "Abington Health, Abington Memorial Hospital, Abington Health Foundation and Lansdale Hospital Boards of Trustees, d/b/a Abington Jefferson Health Boards of Trustees, Meeting Minutes" dated September 25, 2018, revealed no documented evidence contracted or written service agreements were reported or reviewed at the Governing Body Meeting Minutes.

Interview with EMP1 on February 25, 2019, confirmed the facility did not conduct a quality review on services provided by contract or written services agreements at the facility.








Plan of Correction:

The Manager Asplundh Surgery Center is responsible for corrective action and ongoing compliance.
The Surgery Center Governing Body approves services provided by Abington Hospital including laboratory and pathology Service. Quality Review of laboratory and pathology services are included in the Surgery Center quarterly Quality Committee, documented in minutes, and presented to the Governing Body on at least an annual basis for review and comment. To insure ongoing compliance, Quality Committee minutes are reviewed by the Director Regulatory Affairs.



553.4 (b) LICENSURE
Other Functions

Name - Component - 00
If the governing body elects, appoints, or employs officers and administrators to carry out its directives, the authority, responsibility and functions of the positions shall be defined.

Observations:

Based on review of Governing Body meeting minutes and interview with staff (EMP), it was determined that the facility failed to ensure that at least an annual meeting was held for the orderly conduct of Abington Memorial Hospital-Asplundh Surgery Center.

Findings include:

Review on March 2, 2019, of the facility's "Amended and Restated Bylaws of Abington Hospital" revised November 27, 2018, revealed "Article III, Board Role. 3.2.1 The Board shall have responsibility for overall policy and strategic clinical direction of the Hospital with a focus on performance improvement and patient safety, licensure and accreditation, compliance, disaster planning, recommendation of annual operating and capital budgets, risk management and community relations ..."

1) Review of "Abington Health, Abington Memorial Hospital, Abington Health Foundation and Lansdale Hospital Boards of Trustees, d/b/a Abington Jefferson Health Boards of Trustees, Meeting Minutes" dated September 25, 2018, revealed no documented evidence of a review of the operations at Abington Memorial Hospital-Asplundh Surgery Center were discussed.

Interview with EMP1 on February 25, 2019, at approximately 1:00 PM confirmed Abington Memorial Hospital-Asplundh Surgery Center was considered a department of the Hospital. Further interview confirmed there was no review of operations for the Abington Memorial Hospital-Asplundh Surgery Center in the meeting minutes provided at the time of the survey.







Plan of Correction:

The Asplundh Surgery Center develops an independent Governing Body and Medical Executive Committee and establish bylaws and committees for the orderly operations and conduct of the Surgery Center including requirements of 553.4(b). This includes overall policy and strategic clinical direction focusing on performance improvement and patient safety. An annual review of operations specific to the Surgery Center are provided to the Governing Body for review and comment. To insure ongoing compliance, governing body minutes are reviewed by the Director Regulatory Affairs


553.25 (1-6) LICENSURE
Discharge Criteria

Name - Component - 00
553.25 Discharge Criteria

A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.

Observations:


Based on a review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that patients met the required discharge criteria prior to discharge for three of 10 medical records reviewed (MR2, MR3, and MR4).

Findings include:

Review on February 28, 2019, of the facility's policy, "Sedation Policy" dated 6/2018, revealed, " ... E. Post Procedure Discharge Criteria. Further revealed this policy only addressed patients who received IV [intravenous] sedation.

Review on February 28, 2019, of MR2 through MR4 revealed there was no documentation that the patients' level of activity, mental status, pain, bleeding, and nausea and vomiting were assessed prior to discharge.

Interview conducted on February 28, 2019, at 12:35 PM, with EMP2 confirmed that there was no documentation in MR2 through MR4 that the patients' level of activity, mental status, pain, bleeding, and nausea and vomiting were assessed prior to discharge. Further interview confirmed the policy did not include a requirement to evaluate for the patients' level of activity, mental status, pain, bleeding, and nausea and vomiting when the patients had procedures where IV sedation was not administered.





























Plan of Correction:

The Manager Surgery Center is responsible for the corrective action and ongoing compliance.

Discharge criteria for patients receiving local anesthesia will be reviewed to confirm compliance with all elements of discharge criteria in 553.25. Documentation will be reviewed and revised as needed to include all required elements. The discharge policy will be revised to include local anesthesia. The Manager Surgery Center will educate physicians and staff that discharge criteria for patients receiving local anesthesia must be met and documented prior to patient being discharged from the facility.
The Manager Surgery Center/designee will audit five charts per week or all if less than five for three months to insure ongoing compliance with documentation of discharge criteria. Direct feedback will be provided to staff as needed. Results of audit will be reported at the next quarterly Surgery Center Quality Meeting.



553.31 (b) LICENSURE
Administrative Responsibilities

Name - Component - 00
553.31 Management and Administration of Operations
Administrative Responsibilities

(b) Administrative policies, procedures and controls shall be established, documented and implemented to assure the orderly and efficient management of the ASF.


Observations:

Based on interviews with staff (EMP), it was determined the facility failed to develop written administrative policies, procedures and controls to assure the orderly and efficient management of the ambulatory surgery facility.

Findings include:

A request was made to EMP2 on February 28, 2019, at approximately 11:50 AM, for the facility's written administrative policies, procedures and controls for patients receiving local sedation related to discharge criteria, written discharge order and evaluation of patient prior to procedure . None was provided.

Interview with EMP2 on February 28, 2019 at approximately 11:50 AM, confirmed written administrative policies, procedures and controls had not been developed for patients receiving local sedation.

Cross reference:
553.3 (1) Governing Body Responsibilities
553.3 (6) Governing Body Responsibilities
553.25 (1-6) Discharge Criteria
555.22 (a) (1-2) Surgical Services Preoperative Care
555.24 (g) Surgical Services Post Operative


























Plan of Correction:

The Manager Asplundh Surgery Center is responsible for the correction action and ongoing compliance.

The Manager Asplundh Surgery Center will review and revise Surgery Center policies for patients receiving local anesthesia to make sure they include the requirements for:
evaluation of patient prior to procedure and

discharge criteria (vital signs, activity, mental status, pain, bleeding, nausea/vomiting)
and

pre-operative care and education including applicable restrictions upon food and drink before surgery and special preparations to be made by the patient.
and

post operative written discharge order


Policies will be reviewed and approved by medical director and presented at the next quarterly Quality Committee approval. Staff will be educated on policy by the Manager Surgery Center for immediate implementation.



555.3 (b) LICENSURE
Requirements

Name - Component - 00
Privileges granted shall reflect the results of peer review or utilization review programs, or both, specific to ambulatory surgery.

Observations:

Based on review of Medical Staff Bylaws, review of credential files (CF) and interview with staff (EMP), it was determined that the governing body failed to grant privileges to licensed practitioners specific for the Abington Memorial Hospital-Asplundh Surgery Center for 4 of 4 credential files reviewed (CF1, CF2, CF3 and CF4).

Findings include:

Review of "Bylaws of the Abington Hospital Medical, Dental and Podiatric Staff" revised November 27, 2018, revealed "Definitions, Hospital means Abington Memorial Hospital ... which includes its on-campus and off-campus outpatient departments, including without limitation, The Abington Memorial Hospital Endoscopy Center and the Abington Memorial Hospital-Asplundh Surgery Center ..."

Review on February 28, 2019, of CF1, CF2, CF3 and CF4 revealed there was no documentation for delineation of privileges granted specifically for the Abington Memorial Hospital-Asplundh Surgery Center.

Interview with EMP1 on February 28, 2019, at approximately 1:30 PM confirmed that there was no documentation of the identification of the Abington Memorial Hospital-Asplundh Surgery Center or specific privileges granted for the Abington Memorial Hospital Asplundh- Surgery Center.







Plan of Correction:

The Director Medical Staff Services is responsible for the corrective action and ongoing compliance. Medical Staff Bylaws include the Asplundh Surgery Center in their scope of coverage. Surgery Center. Delineation of Practitioner files are updated to reflect privileges at the Asplundh privileges is specifically for the Asplundh Surgery Center.
To insure ongoing compliance practitioner privileges will be reviewed by Director Regulatory Affairs to verify delineated privileges of all medical staff personnel working at Asplundh Surgery Center. Results of review will be to the Quality Committee and annually for Governing Body review.
The written agreement for provision of Medical Staff services by Abington Hospital was confirmed. Quality of Medical Staff services is included the review of contracted services at the Asplundh Surgery Center Quality Committee.


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 review of medical records (MR), and staff interview (EMP), it was determined the practitioner failed to perform an examination of the patient immediately before surgery to evaluate the risk of anesthesia and the procedure to be performed and failed to ensure the history and physical was performed within 30 days of the procedure for four of ten medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Request was made on February 28, 2019 to EMP2 for policy related to examination of the patient immediately before surgery to evaluate the risk of anesthesia and the procedure. None provided.

Request was made on February 28, 2019 to EMP2 for History and Physical policy. Provided Medical Staff Bylaws, "Preamble."

Review on February 28, 2019, of facility's Medical Staff Bylaws dated November 27, 2018, revealed, " ... Preamble ... 3.3-2 ... For same day surgery/procedure patients assure that each patient has had a physical exam and medical history performed no more than 30 days before the scheduled procedure ... ."

Review on February 28, 2019, MR1 through MR4 revealed these patients had surgical procedures between January 14, 2019 and January 28, 2019. Further review revealed there was no documented evidence that the patients were examined immediately before their surgical procedures to evaluate the risk of anesthesia and of the procedure to be performed. Further revealed these patient records did not contain a history and physical exam performed within 30 days prior to the procedure.

Interview with EMP2, on February 28, 2019, at approximately 12:15 PM, confirmed there was no documented evidence in MR1 through MR4 that the patients were examined immediately before their surgical procedures to evaluate the risk of anesthesia and of the procedure to be performed. Further confirmed patients who are not administered IV Sedation are not required to have an examination by practitioner immediately before their surgical procedure. Further confirmed these patient records did not contain a history and physical exam performed within 30 days prior to the procedure.
























Plan of Correction:

The Manager Asplundh Surgery Center is responsible for the correction action and ongoing compliance.
Requirement of the 30-day history and physical timeframe and the requirement for pre-operative examination of patients prior to procedure was reviewed with the physicians and staff during staff meetings in March. Confirmation that this requirement applies to local anesthesia patients was included in the education. Policies for patients receiving local anesthesia will be reviewed and revised as needed to include the requirement for history and physical exam within 30-days and examination of the patient prior to procedure.
The Manager Surgery Center/designee will audit five charts per week of patients receiving local anesthesia, or all if less than five, for three months to insure ongoing compliance with timeliness of history and physical within 30-days and documentation of physical exam prior to procedure. Direct feedback will be provided to staff as needed. Results of audit will be reported at the next quarterly Surgery Center Quality Meeting.



555.22 (c)(1-5) LICENSURE
Surgical Services - Preoperative Care

Name - Component - 00
555.22 Pre-operative Care

(c) Written instruction for preoperative procedures, which have been approved by the medical
staff, shall be given to the patient or responsible person, and shall include:
(1) Applicable restrictions upon food and drink before surgery
(2) Special preparations to be made by the patient
(3) The required proximity of the patient to the ASF for a specific time following surgery if applicable.
(4) An understanding that the patient may require admission to the hospital in the event of medical need.
(5) The requirement that, upon discharge of a patient who has received sedation or general anesthesia, a responsible person shall be available to escort patient home. With respect to patients who receive local or regional anesthesia, a medical decision shall be made regarding whether such patients require a responsible person to escort them home.


Observations:

Based on review of medical records (MR), review of facility policies and interview with staff (EMP), it was determined the facility failed to provide documented evidence that written pre-operative instructions were given to each patient prior to a surgical procedure for ten (10) of ten (10) medical records reviewed. (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10).

Findings include:

Request was made to EMP2 on February 28, 2019, for facility's Pre-Op Instruction Policy. None was provided.

Review on February 28, 2019 of MR1, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR2, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR3, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR4, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR5, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR6, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR7, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR8, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR9, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Review on February 28, 2019 of MR10, revealed that the patient related to this medical record was admitted to the facility and underwent a surgical procedure. No documented evidence in medical records that written pre-operative instructions were provided to patient prior to procedure.

Interview on February 28, 2019 at approximately 12:00 PM, with EMP2 confirmed there was no documentated evidence that written pre-operative instructions were provided to each patient listed in MR1 through MR10. EMP2 further confirmed that the facility does not provide patients with pre-operative instructions in a written format.





Plan of Correction:

The Manager Asplundh Surgery Center is responsible for the correction action and ongoing compliance.

The physicians and staff were re-educated by the Manager Surgery Center of the requirement to verify that written pre-operative instructions were given to the patient prior to the procedure and document that evidence in the patient medical record. Education occurred during staff meetings in March and April.
The Manager Surgery Center/designee will audit five charts per week for three months of documented evidence that written preoperative instructions were given to each patient prior to the surgical procedure. Direct feedback will be provided to staff as needed. Results of audit will be reported at the next quarterly Surgery Center Quality Meeting.



555.24 (g) LICENSURE
Surgical Services - Postoperative

Name - Component - 00
555.24 Post Operative Care

(g) Patients shall be discharged only upon the written signed order of a practitioner.


Observations:


Based on review of facility policies and procedures, review of medical records (MR), and interviews with staff (EMP), it was determined the facility failed to ensure patients were discharged only upon a written signed order of a practitioner for four of ten medical records reviewed (MR1, MR2, MR3, and MR4).

Findings include:

Request was made on February 28, 2019 to EMP2 for policy related to Practitioner Discharge Order. None provided.

Review on February 28, 2019, of MR1, MR2, MR3 and MR4 revealed these patients had a procedure at the facility between January 14, 2019 and January 28, 2019. Further review revealed there was no written discharge order signed by practitioner.

Interview with EMP2 on February 28, 2019, at 1:54 PM confirmed there was no documented evidence in MR1, MR2, MR3, and MR4 that a written discharge order was signed by a practitioner. Further confirmed a written discharge order is not completed for patients who were not administered IV Sedation.




















Plan of Correction:

The Manager Asplundh Surgery Center is responsible for the correction action and ongoing compliance.
The physicians and staff were re-educated by the Manager Surgery Center that patients including those receiving local anesthesia cannot be discharged without signed written order. Education occurred during staff meetings in March and April.
The Manager Surgery Center/designee will audit five charts per week for three months to insure that a signed written order is present before patient discharge. Direct feedback will be provided to staff as needed. Results of audit will be reported at the next quarterly Surgery Center Quality Meeting



569.3 LICENSURE
Policies and Procedures

Name - Component - 00
569.3 Policies and Procedures

Written policies and procedures for use in preventing and
responding to fire and disaster shall be made available to personnel.

Observations:

Based on facility policy and interview with staff (EMP), it was determined the facility failed to have written policies and procedures for preventing and responding to disasters.

Findings include:

A request was made on February 28, 2019, at approximately 1:00 PM to EMP3 for the facility's internal disaster plan. None provided.

An interview conducted on February 28, 2019, at approximately 1:30 PM to EMP2 confirmed the facility did not have a disaster policy available.










Plan of Correction:

The Manager Surgery Center is responsible for the corrective action and ongoing compliance.

Current disaster plan was not specific to Asplundh Surgery Center. The Manager Surgery Center will collaborate with the Public Safety Officer to review and revise internal disaster plan to be specific to Asplundh Surgery Center. The internal disaster plan will be presented and the next quarterly Safety Committee Meeting for approval. Internal disaster plan will be reviewed with staff after Safety Committee approval.



569.14 LICENSURE
Internal Disaster and Fire Plans

Name - Component - 00
569.14 Internal Disaster and Fire Plans

The ASF shall have an internal disaster and fire plan incorporating
evacuation procedures and the safety of both closed records and the records
of those patients being evacuated. These plans shall be made available to
personnel and evacuation diagrams shall be posted throughout the ASF.


Observations:

Based on a review of facility documents and staff interview (EMP), it was determined that the Abington Memorial Hospital-Asplundh Surgery Center failed to ensure an annual internal/external disaster drill was conducted.

Findings include:

Request was made on February 28, 2019, for the facility's disaster plan. None provided.

Request was made to review a written evaluation of the facility's internal/external disaster drill. None provided.

An interview was conducted with EMP1 on February 28, 2019, at approximately 1:30 PM confirmed the above findings.







Plan of Correction:

The Manager Surgery Center is responsible for the corrective action and ongoing compliance.
The annual internal/external disaster drill is scheduled for March 26, 2019 by the Director Public Safety. An evaluation and debrief of the disaster drill will be completed and presented at the quarterly Safety Meeting. Annual disaster drills will be scheduled through the Director of Public Safety going forward with evaluations presented at the Endoscopy Center Safety Committee.