Nursing Investigation Results -

Pennsylvania Department of Health
PROGRESSIVE SURGICAL INSTITUTE, INC.
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PROGRESSIVE SURGICAL INSTITUTE, INC.
Inspection Results For:

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PROGRESSIVE SURGICAL INSTITUTE, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
This report is the result of a State licensure survey conducted on November 14 - 15, 2019, at Progressive Surgical Institute, Inc. 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:


555.3 (b) LICENSURE Requirements:State only Deficiency.
Privileges granted shall reflect the results of peer review or utilization review programs, or both, specific to ambulatory surgery.
Observations:

Based on review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure peer review was performed with physician recredentialing for three of six credential files reviewed (CF1, CF5 and CF6).

Findings include:

Review on November 14, 2019 of the facility's "Governing Body Bylaws," last reviewed September 30, 2019, revealed "Governing Body Bylaws Progressive Surgical Institute ... Whereas, the governing body, the medical staff, and any of their committees or agents, in order to promote professional peer review activity designated to establish a harmonious environment in which appropriate standards of medical care may be achieved, constitute themselves as professional review bodies as defined in the Health Care Quality Improvement Act of 1986, and claim all of the privileges and immunities of this act. ... Definitions Governing Body The individual(s), group, or agency that has ultimate authority and responsibility for the overall operation of the organization. ... Peer Review Peer Review is completed by a physician / anesthesiologist reviewing medical records of another peer on a monthly basis ... at least 2 medical records are reviewed a month. Any unusual occurrences/incidents are reviewed by a peer on a case by case basis to review that a standard of care was maintained. A summary of the peer review is done and presented to the governing body on an annual basis as well as being reviewed at the time of recredentialing. The governing body is responsible with reviewed peer review activities. These activities are utilized when making a determination concerning qualifications of a professional health care provider of patient care rendered by professional health care providers, or the merits of a complaint against a professional health care provider. Peer review shall include the accuracy of diagnosis, propriety, quality, appropriateness, or necessity of care, utilization of services, procedures and facilities of the center, and the no disruptive nature of the care. ..."

Review of the facility's governing Body meeting minutes dated December 20, 2018, revealed the governing body reviewed and approved CF1, CF5 and CF6 for recredentialing at the facility.

Review of CF1, CF5 and CF6 on November 14, 2019, revealed no documentation the facility completed peer review on these physicians at the time the governing body reviewed and approved these physicians recredentialing at the facility.

Interview with EMP1 and EMP2 on November 14, 2019, at approximately 1:30 PM confirmed the governing Body meeting minutes dated December 20, 2018, indicating the governing body reviewed and approved CF1, CF5 and CF6 for recredentialing and there was no documentation the facility completed peer review on CF1, CF5 and CF6 at the time the governing body reviewed and approved these physicians recredentialing at the facility. EMP1 and EMP2 revealed peer review was part of the recredentialing process.





 Plan of Correction - To be completed: 12/30/2019

The Governing Body Bylaws,Peer Review process has been updated to state that peer review on medical records will be done on at least 2 records a month when applicable for a provider. If a provider has not provided care in a given year to be able to complete peer review on a medical record then a Professional Peer Reference Questionnaire will be sent to a reference practitioner/facility to be completed on an annual basis.

For CF1, CF5, and CF6 a Professional Peer Reference Questionnaire will be obtained and placed in the peer review binder. This will completed by the Clinical Directors. Peer review activities will be monitored on a monthly basis by the Clinical Directors. A report will be kept in the scheduling book listing providers for each surgery day and it will be used to note that peer review forms have been completed for a given month. A list of credentialed physicians will be kept with this report to be marked when the annual peer review has been summarized.

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