Pennsylvania Department of Health
WILLS SURGERY CENTER AT THE PHILADELPHIA STADIUM CAMPUS
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WILLS SURGERY CENTER AT THE PHILADELPHIA STADIUM CAMPUS - 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 September 27, 2023, at Wills Surgery Center At The Philadelphia Stadium Campus. 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:

553.3 (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 interview with staff (EMP), it was determined the facility failed to conform to all applicable State Laws.

The facility was not in compliance with the following State Law related to Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act 40 PS. Patient Safety Committee

Section 310. Patient Safety Committee

(a) Composition ...
(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 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."

Based on review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure a member of the community attended the Patient Safety Committee Meetings.

This was not met as evidenced by:

Finding include:

Review of facility document "Patient Safety Program" last reviewed February 2023, revealed "The Committee shall consist of at least the following members: b. (1) Community Member who is not an agent, employee or contractor of Wills Surgery Center At The Philadelphia Stadium Campus"

Review of Wills Surgery Center At The Philadelphia Surgery Center Patient Safety Meeting Minutes dated December 28, 2022, March 14, 2023, June 28, 2023 and September 22, 2023, revealed a community member was not in attendance.

An interview conducted on September 27, 2023 at 10:18 AM with EMP1 confirmed the facility did not have a community member in attendance at the Patient Safety Committee Meetings.

Plan of Correction - To be completed: 10/10/2023

1. A new member of the community has been appointed to the Safety Committee.
2. Members of the Safety Committee have been informed and approve of the new member. This new member of the committee has a cellular telephone and access to a computer in case she is not able to attend the Safety Committee meetings in person.
3. Safety Committee minutes will reflect the new members name on the committee minutes and her signature on the attendance signature sheet.
4. The new members name will be shared with the QA committee and the MAB in the month of December 2023.
5. The plan of correction is the responsibility of the Administrator and the Medical Director.

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