Pennsylvania Department of Health
NORTH SHORE ENDOSCOPY 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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NORTH SHORE ENDOSCOPY CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced special monitoring survey completed on May 23, 2023, at North Shore Endoscopy 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:

553.31 (a) LICENSURE Administrative responsibilities:

A full time person in charge shall be appointed who has authority and responsibility for the operation of the ASF at all times. Qualifications, authority, responsibilities and duties of the person in charge shall be defined in a written statement adopted by the governing body.

Observations:

Based on review of a facility documents and staff interviews (EMP), it was determined the facility failed to ensure a full-time person in charge of the surgery center at all times.
Findings include:
Review of a document dated May 1, 2023, revealed the facility requested an exception to 28 Pa. Code 553.31(a) Administrative responsiblities. The exception was denied.
Review of a letter provided to the Department of Health on May 9, 2023, revealed two nurses would share the responsibility for the daily operational (Administration) oversight of the facility. The letter also indicated the the previous administrator assumed the administrator role at another facility as of April 10, 2023.
At the time of the review, EMP1 confirmed there was no full time person in charge. EMP1 further confirmed two nurses were sharing the responsiblities of the administrator.

Plan of Correction - To be completed: 12/18/2023

An approved Plan of Correction is not on file.

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