Pennsylvania Department of Health
 SPARTAN HEALTH SURGICENTER, LLC
Patient Care Inspection Results

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SPARTAN HEALTH SURGICENTER, LLC
Inspection Results For:

There are  28 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SPARTAN HEALTH SURGICENTER, LLC - 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 May 9, 2023, at Spartan Health Surgicenter. 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 STANDARD Governing Body Responsibilities:State only Deficiency.
§ 553.3. Governing body responsibilities.
Observations:

Based upon a review of facility documents and staff interview (EMP), it was determined that the facility's Governing Board failed to adopt the policies and procedures to ensure the quality of care was evaluated and issues were appropriately addressed.
Findings include:
On May 9, 2023, the Quality Assurance Performance Improvement, Risk Management, the Utilization Review Plans were reviewed. The cover sheet indicated that the contents had been reviewed and approved by the Shareholders on January 3, 2023.
On May 9, 2023, the minutes of the Shareholder's meetings (Governing Body) were reviewed and included proceedings from December 14, 2022; January 31, 2023; and February 23, 2023. Further review of the meeting minutes revealed no evidence that the policies, procedures, plans, or quality data had been reviewed or approved on January 3, 2023.
On May 9, 2023, at 12:30 pm, EMP1 was unable to provide minutes demonstrating that the governing body had reviewed policies and procedures, Quality Plan, Risk Management Plan, Utilization Review Plan, and review of quality data by the Shareholders.
On May 9, 2023, at 12:40pm, EMP2 confirmed that Policies and Procedures, Quality Plan, Risk Management Plan, Utilization Review Plan, and Quality Data were not discussed in the Shareholder's meetings on December 14, 2023; January 31, 2023; and February 23, 2023. There was no special meeting of the Shareholders documented for January 3, 2023.










 Plan of Correction - To be completed: 06/05/2023

The policies, procedures, plans, and quality data for 2023 was approved 6/1/23 at the last board meeting. Moving forward, the policies, procedures, plans, and quality data for each will be approved at the last board meeting of the year.

This will be overseen by the administrator and QAPI will be performed on the 6/1/23 board and the last board meeting minutes of the year by the administrator.
555.33 (d)(1) LICENSURE Anesthesia Policies and Procedures:State only Deficiency.
555.33 Anesthesia policies and procedures

(d) Anesthesia procedures shall provide at least the following:
(1) A patient requiring anesthesia shall have a pre-anesthesia evaluation by a practitioner, with appropriate documentation of pertinent information regarding the choice of anesthesia.

Observations:


Based on review of facility materials, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that the patient requiring anesthesia received a pre-anesthesia evaluation by a practitioner for eight of ten medical records reviewed (MR1, MR3, MR4, MR5, MR7, MR8, MR9, and MR10).
Findings include:
On May 9, 2023, review of facility policy "Patient Care Procedures" last dated unknown, revealed "...Patients having MAC or general anesthesia are prepared for surgery: A. An Anesthesia provider interviews the patients, explains the anesthesia and obtains informed consent...".
On May 9, 2023, review of MR1, date of service 2/1/23, revealed that the pre-anesthesia evaluation was not completed by a practitioner.
On May 9, 2023, review of MR3, date of service 11/18/22, revealed that the pre-anesthesia evaluation was not completed by a practitioner.
On May 9, 2023, review of MR4, date of service 4/28/23, revealed that the pre-anesthesia evaluation was not completed by a practitioner.
On May 9, 2023, review of MR5, date of service 4/27/23, revealed that the pre-anesthesia evaluation was not completed by a practitioner.
On May 9, 2023, review of MR7, date of service 4/26/23, revealed that the pre-anesthesia evaluation was not completed by a practitioner.
On May 9, 2023, review of MR8, date of service 4/26/23, revealed that the pre-anesthesia evaluation was not completed by a practitioner.
On May 9, 2023, review of MR9, date of service 4/26/23, revealed that the pre-anesthesia evaluation was not completed by a practitioner.
On May 9, 2023, review of MR10, date of service 4/26/23, revealed that the pre-anesthesia evaluation was not completed by a practitioner.
On May 9, 2023, at 11:50am, EMP3 confirmed the above findings.




 Plan of Correction - To be completed: 06/07/2023

The pre-anesthesia evaluation on all patients receiving MAC or general anesthesia will be completed by a practitioner. All staff be educated by administration on this manner to be completed by 6/30/23. QAPI will be performed on 10 medical records by the DON. To ensure that the pre-anesthesia evaluations are completed by a practitioner. This is to be done monthly by the DON until 100% compliance is achieved for 90 consecutive days. Going forward, quarterly QAPI will be conducted.
563.12 (7) LICENSURE Form and Content of Record:State only Deficiency.
563.12 Form and content of record

The ASF shall maintain a separate medical
record for each patient. Each record shall be accurate, legible and
promptly completed. Patient medicals shall be constructed to stand alone and be easily identified as ASF records. Medical records must include at least the following:
(7) Findings and techniques of the operation, including a pathologist report on tissue removed during surgery.
Observations:


Based on review of facility materials, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that the record of findings and techniques of the operation were accurate for four of ten medical records reviewed (MR3, MR7, MR9, and MR10).

Findings include:

On May 9, 2023, review of facility document "Timely Entry of Data-Operative Reports", last dated unknown, revealed "...The verbal dictation including the findings and techniques of an operation or procedure is to be completed immediately after the surgery is performed by the surgeon (or his resident, physician assistant or nurse practitioner if applicable) ...Typed operative room reports will be signed by the surgeon ... " .

On May 9, 2023, review of MR3, date of service 11/18/22, revealed that a partner of the surgeon's practice, who was not present for the procedure, signed the dictated operative report.

On May 9, 2023, review of MR7, date of service 4/26/23, revealed that a partner of the surgeon's practice, who was not present for the procedure, signed the dictated operative report.
On May 9, 2023, review of MR9, date of service 4/26/23, revealed that a partner of the surgeon's practice, who was not present for the procedure, signed the dictated operative report.

On May 9, 2023, review of MR10, date of service 4/26/23, revealed that a partner of the surgeon's practice, who was not present for the procedure, signed the dictated operative report.

On May 9, 2023, at 11:50am, EMP3 confirmed the above findings.




 Plan of Correction - To be completed: 06/07/2023

The staff and physicians will be educated that all entries in the medical records shall be dated and authenticated by the person making the entry.

This will be completed by 7/7/23. QAPI will be performed by the DON on 10 medical records monthly to ensure that all entries in the medical record shall be dated and authenticated by the person making the entry until 100% compliance is achieved for 90 consecutive days. Going forward, QAPI will be conducted for three consecutive quarters.
563.13 (a) LICENSURE Entries:State only Deficiency.
563.13 Entires

(a) Entries in the record shall be dated and authenticated by the person making the entry.
Observations:


Based on review of facility materials, review of medical records (MR), and interview with facility staff (EMP). It was determined that the facility failed to ensure that all entries were dated and authenticated by the person making the entry for ten of ten medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, and MR10).

Findings include:

On May 9, 2023, review of facility document "Spartan Health Surgicenter Medical Records Policy " , last dated unknown, revealed " ...All forms in the medical record are dated and signed by the proper personnel ... " .

On May 9, 2023, review of facility document "Patient Consent", last dated unknown, revealed it did not address the need for dates with signatures.

On May 9, 2023, review of facility document "Timely Entry of Data-Operative Reports", last dated unknown, revealed "...Typed operative reports will be signed by the surgeon and entered into the patient's medical record ...". Dating the signature is not addressed.

On May 9, 2023, review of MR1, date of service 2/1/23, revealed that the anesthetist did not date their signature on the anesthesia consent form. Further review revealed that the physician did not date their signature on the operative report.

On May 9, 2023, review of MR2, date of service 12/23/22, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, review of MR3, date of service 11/18/22, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, review of MR4, date of service 4/28/23, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, review of MR5, date of service 4/27/23, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, review of MR6, date of service 4/28/23, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, review of MR7, date of service 4/26/23, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, review of MR8, date of service 4/26/23, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, review of MR9, date of service 4/26/23, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, review of MR10, date of service 4/26/23, revealed that the physician, nor the anesthetist dated their signatures on the procedure and anesthesia consent forms. Further review revealed that physician did not date their signature on the operative report.

On May 9, 2023, at 11:50am, EMP3 confirmed the above findings.




 Plan of Correction - To be completed: 06/07/2023

The facility will ensure that all entries into the medical records shall be signed
and dated by the appropriate personnel. All staff and physicians will be educated on this matter by the DON and to be completed by 7/7/23. QAPI will be performed by the DON monthly on 10 medical records to ensure that all entries into the medical records are signed and dated by the appropriate personnel until 100% compliance is achieved for 90 consecutive days. Going forward, QAPI will be conducted for three consecutive quarters.
567.43 LICENSURE Ventilation System:State only Deficiency.
The ventilation system shall be inspected and maintained in accordance with the written maintenance schedule to ensure that a properly conditioned air supply meeting minimum filtration, humidity and temperature requirements is provided in critical areas such as the surgical and recovery suites under
Chapter 571 (relating to construction standards).

Observations:


Based on review of facility documents and interview with facility staff (EMP), it was determined that the facility failed to ensure proper temperature requirements were provided in recovery suites.

Findings include:

On May 9, 2023, review of facility material " Safety Monitoring " last date unknown, revealed " ...SURGERY AND CRITICAL CARE ...Recovery room ...Design Temperature 70-75 degrees Fahrenheit ... " .

On May 9, 2023, review of recovery room temperature logs revealed temperature range 68-73 degrees Fahrenheit. March 13, 2023, 68 degrees Fahrenheit, April 4 and 5, 2023, 68 degrees Fahrenheit, May 3, 2023, 68 degrees Fahrenheit, and May 8, 2023, 69 degrees Fahrenheit.

On May 9, 2023, at 11:50am, EMP3 confirmed the above findings.




 Plan of Correction - To be completed: 06/05/2023

The facility will ensure that the temperature in the recovery area will be maintained in the 70-75 degree range by updating the policy to include the next step actions if not in prescribed range.

Education on this matter will be performed by the DON by 7/7/23. Temperatures will be logged daily in this area. QAPI will be performed weekly by the DON until 100% compliance is achieved in 90 consecutive days. Going forward, QAPI will be conducted for three consecutive quarters.

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