Pennsylvania Department of Health
PENNSYLVANIA EYE SURGERY CENTER, INC.
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PENNSYLVANIA EYE SURGERY CENTER, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a full State Licensure survey initiated on February 4, 2025 and concluded on February 7, 2025 at Pennsylvania Eye Surgery Center, 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:

555.22 (e) LICENSURE Surgical Services - Preoperative:

555.22 Pre-operative Care

(e) Prior to the administration of anesthesia, it is the responsibility of the primary operating surgeon and the person administrating anesthesia to properly identify the patient and the procedure to be performed and to document this identification in the patient's medical record. This procedure shall be in written policies designating the mechanism to be used to identify each surgical patient.

Observations:

Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined that the facility failed to document the identification of the patient by the anesthesiologist for two of ten medical records reviewed (MR4 and MR9).

Findings include:

A review of facility policy, "Surgical Services Operative Procedures Policy" on February 7, 2025, at approximately 1:00 PM, revealed "... The patient is brought to the OR by nursing staff and anesthetist, identified by identification tag, medical record, and verbal introduction, with the patient responding correctly when possible ..."

A review of MR4 and MR9 on February 7, 2025, at approximately 10:30 AM revealed the anesthesiologist did not document that the patient had been identified prior to the administration of sedation or analgesia.

An interview with EMP1 on February 7, 2025, at approximately 1:30 PM confirmed that MR4 and MR9 did not contain documentation that the patient had been identified prior to the administration of sedation or analgesia.

Plan of Correction - To be completed: 02/20/2025

The Nurse Manager has spoken with the anesthesia providers and reviewed the present policy pertaining to patient verification.
Signed in-services will be conducted with the anesthesia providers and staff to re-educate them on the policies and procedures and will be completed by 2/20/2025. The In-services will be available for review by 2/20/2025.
The anesthesia providers will check the appropriate pre-op boxes as it pertains to each individual patient.
An email will be sent to all the anesthesia providers instructing them to follow the policy regarding patient verifications.
The Nurse Manager will monitor the progress of the anesthesia providers patient verifications and chart entries. 100% of all medical records will be audited daily, weekly and monthly, until 100% compliance is met. Once compliance is met, Once compliance is met, continued compliance will be achieved through quarterly chart review, which is already part of the QAPI process, consisting of 10 Medical Records per physician per month. Continued compliance will be achieved through quarterly chart review, which is already a part of our QAPI process
The Administrator will monitor the progress of the nurse manager.
The results will be reported to the Board and to QAPI.

555.23 (f) LICENSURE Surgical Services - Operative Care:

555.23 Operative Care

(f) There shall be a written agreement in effect with an ambulance service staffed by certified EMT personnel, for the safe transfer of a patient to a hospital in an emergency situation, or as the need arises.

Observations:

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to have a written agreement with an ambulance service.

Findings include:

A review of the facility's contracted services agreements on February 7, 2025, at approximately 12:00 PM, reveal that the facility did not have a contract or written agreement with an ambulance service.

An interview with EMP1 on February 7, 2025, at approximately 1:30 PM confirmed the facility did not have a written agreement or contract with an ambulance service.

Plan of Correction - To be completed: 02/20/2025

The Administrator will ensure that the ASF has a written agreement with an ambulance service.
The Nurse Manager will contact local ambulance services and obtain a written agreement.
The Administrator will inform the board of the decision on the vendor chosen for their approval.
A Board meeting will be held on 2/20/2025 for approval of the chosen ambulance vendor.
Once signed the nurse manager will keep a copy of the agreement in the vendor contract binder.
The Administrator will monitor the progress of the nurse manager.
The contract will be added to the vendor evaluation checklist for the annual Board approval. This task will be accomplished by 2/20/2025.
The results will be reported to the Board and to QAPI.

555.33 (d)(3) LICENSURE Anesthesia Policies and Procedures:

555.33 Anesthesia policies and procedures

(d) Anesthesia procedures shall provide at least the following:
(3) Prior to beginning the administration of anesthesia, the anesthetist shall check equipment to be used in administration of anesthetic agents. An anesthetic gas machine in anesthetising areas shall have a pin-index system.

Observations:

Based on review of facility policy, medical records (MR) and staff interview (EMP), it was determined that the facility was unable to provide evidence that the anesthesia machine was checked prior to being used for procedures in two of ten medical records reviewed (MR4, MR9).

Findings include:

A review of facility policy, "Anesthesia Organization and Functions of Anesthesia Care Policy" on February 7, 2025, at approximately 1:00 PM, revealed "... Prior to beginning anesthesia, the anesthetist will check all anesthesia equipment to be used. ..."

A review of MR4 and MR9 on February 7, 2025, at approximately 10:30 AM revealed the medical records do not contain documentation that the anesthesia equipment was checked prior to the beginning of anesthesia.

An interview with EMP1 on February 7, 2025, at approximately 1:30 PM confirmed that MR4 and MR9 did not contain documentation that the anesthesia equipment was checked.

Plan of Correction - To be completed: 02/20/2025

The Nurse Manager has spoken with the anesthesia providers and reviewed the present policy pertaining the anesthesia equipment check prior to patient care.
The anesthesia providers will check the appropriate pre-op boxes as it pertains to the equipment checks.
An email will be sent to all the anesthesia providers instructing them to follow the policy regarding anesthesia equipment check prior to start of sedation.
A signed In-service will be conducted with the anesthesia providers and staff to re-educate them on the policies and procedures by 2/20/2025. The In-services will be available for review and will be completed by 2/20/2025.
The Nurse Manager will monitor the progress of the anesthesia providers equipment checks and chart entries, daily, weekly and monthly until compliance is met. The Nurse Manager will monitor the progress of the anesthesia providers patient verifications and chart entries. 100% of all medical records will be audited daily, weekly and monthly, until 100% compliance is met. Once compliance is met, continued compliance will be achieved through quarterly chart review, consisting of 10 Medical Records per physician per month, which is already a part of our QAPI process.
The Administrator will monitor the progress of the nurse manager.
The results will be reported to the Board and to QAPI.

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