Pennsylvania Department of Health
HOLY REDEEMER AMBULATORY SURGERY CENTER LLC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HOLY REDEEMER AMBULATORY SURGERY CENTER LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced onsite revisit survey conducted on August 7, 2024, following a State Licensure survey completed on March 28, 2024, at Holy Redeemer Ambulatory 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:

551.101 LICENSURE Correction of Deficiency - Policy:

551.101 Policy

If an ASF notifies the Department that it has completed a plan of correction and corrected its
deficiencies, the Department will conduct a survey to ascertain completion of the plan of correction.
Upon finding full or substantial compliance, as defined in 551.82 (b)(relating to a regular license),
the Department will issue a regular license.

Observations:

Based on review of the facility's Plan of Correction (PoC), facility documents and interview with staff (EMP), it was determined the facility failed to correct deficient practice by failing to follow the Plan of Correction submitted and accepted by the Department for the survey dated March 28, 2024. The corrective action date as approved by the Department May 30, 2024.

Findings include:

Review on August 7, 2024, of the facility's PoC statement for 553.3 (1) Governing Body Responsibilities, revealed "Corrective Action ... Patient Safety committee for the ASC will be developed by Administrator and will consist of one resident of the community served by the ambulatory surgical facility. The committee will also include Administrator, DON, Medical Director/PSO, BOM member and staff of the facility. It will meet quarterly as required and will begin July 2024. Results of meeting will be reported to the PRC committee and BOM in subsequent meetings. This committee will discuss safety issues for the quarter and review clinical events (Incident, Serious and Infrastructure) as reported to PAPSR's. Identify any trends and mitigate any future safety issues. This will be monitored for completion by administrator. In addition to the Safety committee, an Infection control committee will also be established with same members and review any and all Infection control issues that may arise in ASC (staff and Patients alike) in the quarter. review of Infection control survey sent to physicians monthly and any CSR issues that may have occurred. This will also commence July 2024 and will be monitored for completion by Administrator ... "

Interview on August 7, 2024, at 10:05 AM, with EMP1 confirmed the ASC Patient Safety Committee and Infection Control Committee had not had a meeting. Further interview with EMP1 confirmed that a community member has not been included in the committee member lists.

Plan of Correction - To be completed: 08/21/2024

Beginning August 21,2024 in conjunction with Health System Patient Safety committee meeting which will be held August 21, 2024 and already include BOM member of ASC, Administrator and Medical Director of ASC, Infection control officer of Health System, Various Staff and a community member, The ASC will conduct Patient safety meetings and will then continually meet quarterly after Health system meetings. Results of these ASC meetings will be reported to subsequent PRC and BOM meetings, which occur within 3 weeks of the PS and IC meetings. The next meeting of the PS and IC committees will be held November 21, 2024. This meeting will also be held quarterly, conducted and Monitored for compliance by the Administrator

Results of these ASC meetings will be reported to subsequent PRC and BOM meetings, which occur within 3 weeks of the PS meetings. The next meeting of the PS committees will be held November 21, 2024.

553.3 (1) LICENSURE Governing Body Responsibilities:

553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.

Observations:

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to conform to an applicable state law.

Holy Redeemer Ambulatory Surgery Center was not in compliance with the following State Law:

"Act 13 of 2002 Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 3. Patient Safety ... Section 310. Patient safety committee ... (2) An ambulatory surgical facility's or birth center's patient safety committee shall be composed of the medical facility's patient safety officer and at least one health care worker of the medical facility and one resident of the community served by the ambulatory surgical facility or birth center who is not an agent, employee or contractor of the ambulatory surgical facility or birth center. No more than one member of the patient safety committee shall be a member of the medical facility's board of governance. The committee shall include members of the medical facility's medical and nursing staff. The committee shall meet at least quarterly ..."

This is not met as evidenced by:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conduct quarterly Patient Safety Committee meetings and failed to fulfill the requirement of having a community member on the committee.

Findings include:

A request was made on August 7, 2024, for the facility's Patient Safety Committee meeting minutes. None provided.

A request was made on August 7, 2024, for the facility's Patient Safety Committee member's list.

Interview on August 7, 2024, at 10:03 AM, with EMP1 confirmed the ASC Patient Safety Committee meetings have not been conducted as required by the facility's plan of correction. Further interview with EMP1 confirmed that a community member has not been added to the committee.

_____________

"Section 310(b) Responsibilities --A patient safety committee of a medical facility shall do all of the following: (1) Receive reports from the patient safety officer pursuant to section 309. (2) Evaluate investigations and actions of the patient safety officer on all reports. (3) Review and evaluate the quality of patient safety measures utilized by the medical facility. A review shall include the consideration of reports made under sections 304(a)(5) and (b), 307(b)(3) and 308(a). (4) Make recommendations to eliminate future serious events and incidents. (5) Report to the administrative officer and governing body of the medical facility on a quarterly basis regarding the number of serious events and incidents and its recommendations to eliminate future serious events and incidents ..."

This is not met as evidenced by:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure reports of incidents were reported at the Patient Safety Committee Meeting.

A request was made on August 7, 2024, for the facility's patient safety meeting minutes that documented incident reports were received from the patient safety officer that evaluated investigations and actions of the patient safety officer concerning these reports. None provided.

Interview on August 7, 2024, at 10:03 AM, with EMP1 confirmed the Patient Safety Committee meetings have not been conducted as required by the facility's plan of correction.

_____________

"Medical Care Availability and Reduction of Error (MCARE) Act - Reduction and Prevention of Health Care -ACT of July. 20, 2007, P.L. 331, No. 52, Chapter 4, Health Care-Associated Infections... Section, 403. Infection control plan. (a) Development and compliance.--Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include: (1) A multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility: (i) Medical staff that could include the chief medical officer...(ii) Administration representatives that could include the chief executive officer, the chief financial officer...(iii) Laboratory personnel. (iv) Nursing staff that could include a director of nursing or a nursing supervisor. (v) Pharmacy staff that could include the chief of pharmacy. (vi) Physical plant personnel (vii) A patient safety officer. (viii) Members from the infection control team, which could include an epidemiologist. (ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility ... "

This is not met as evidenced by:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conduct quarterly Infection Control Committee meetings and failed to fulfill the requirement of having a community member on the committee.

Findings include:

A request was made on August 7, 2024, for the facility's Infection Control Committee meeting minutes. None provided.

A request was made on August 7, 2024, for the facility's Infection Committee member's list.

Interview on August 7, 2024, at 10:05 AM, with EMP1 confirmed the ASC Infection Control Committee meeting have not been conducted as required by the facility's plan of correction. Further interview with EMP1 confirmed that a community member has not been added to the committee.

Plan of Correction - To be completed: 08/21/2024

Beginning August 21,2024 in conjunction with Health System Patient Safety committee meeting which will be held August 21, 2024 and already include BOM member of ASC, Administrator and Medical Director of ASC, Infection control officer of Health System, Various Staff and a community member, The ASC will conduct Patient safety meetings and will then continually meet quarterly after Health system meetings. Results of these ASC meetings will be reported to subsequent PRC and BOM meetings, which occur within 3 weeks of the PS and IC meetings. The next meeting of the PS and IC committees will be held November 21, 2024. This meeting will also be held quarterly, conducted and Monitored for compliance by the Administrator

On August 21, 2024 following the PS meeting the ASC will conduct an Infection control meeting which will include BOM member of ASC, Administrator and Medical Director of ASC, Infection control officer of Health System, Various Staff and a community member. This meeting will also be held quarterly, conducted and Monitored for compliance by the Administrator

Results of these ASC meetings will be reported to subsequent PRC and BOM meetings, which occur within 3 weeks of the PS and IC meetings. The next meeting of the PS and IC committees will be held November 21, 2024.

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