Observations:
Based on review of facility documents, facility policy, credential files (CF), and staff interview (EMP), it was determined that facility failed to ensure that the privileges granted reflected the results of peer review or utilization review programs, specific to the ambulatory surgery center for seven of seventeen credential files reviewed (CF1, CF2, CF3, CF4, CF5, CF6, and CF7).
Findings include:
On February 29, 2024, at approximately 10:00 AM a review of Medical Staff Bylaws adopted by the governing board on April 27, 2003, revealed, "Article II. Responsibilities Of The Medical Staff ... participating in the total quality management program by conducting objectively all required peer evaluation activities through medical staff review ..."
On February 29, 2024, at approximately 10:15 AM a review of facility policy "Peer Review/Utilization Review Subcommittee" without a referencing date, revealed "The function of the Peer Review/Utilization Review Subcommittee shall be to assess the quality and appropriateness of care delivered by the facility medical staff. This is accomplished through an ongoing quarterly review of cases against established criteria. Further responsible for maintaining peer review documentation on all physicians in the facility, for reference and utilization in the appointment and reappointment process."
On February 29, 2024, a review of credentialing files revealed that CF1 lacked evidence of peer review.
On February 29, 2024, a review of credentialing files revealed that CF2 lacked evidence of peer review.
On February 29, 2024, a review of credentialing files revealed that CF3 lacked evidence of peer review.
On February 29, 2024, a review of credentialing files revealed that CF4 lacked evidence of peer review.
On February 29, 2024, a review of credentialing files revealed that CF5 lacked evidence of peer review.
On February 29, 2024, a review of credentialing files revealed that CF6 lacked evidence of peer review.
On February 29, 2024, a review of credentialing files revealed that CF7 lacked evidence of peer review.
On February 29, 2024, at approximately 10:30 AM, interview with EMP1 confirmed that the credential files CF1, CF2, CF3, CF4, CF5, CF6, and CF7 lacked evidence of peer review per policy.
| | Plan of Correction - To be completed: 03/19/2024
The Pennsylvania Eye & Ear Surgery Center peer review process is outlined below:
"Review against specific criteria, of a minimum of 5% or 20 (whichever is greater) randomly selected records of cases in each specialty, performed during the most recent quarter to monitor quality and appropriateness of care provided."
During the survey, it was discovered that anesthesia peer review was not conducted appropriately. To correct this, anesthesia peer review will be conducted along the same guidelines and timeframe as peer review for all providers of the facility.
Pennsylvania Eye and Ear Surgery Center is currently gathering Peer Reviews for the anesthesia service for the first quarter of 2024. A meeting of the Peer Review Subcommittee will take place in the second quarter of 2024 to evaluate the results of the first quarter sample of cases. Five (5) percent of cases from the first quarter of 2024 will be evaluated during the above meeting.
In preparation for the Peer Review Subcommittee meeting, the Clinical Director will determine the correct number of cases to be reviewed, supervise the selection of cases, oversee completion of the reviews, analyze the results, and report any issues to the Peer Review Subcommittee. Any issues discovered in the review process will be managed immediately as per the Board approved recommendations of the Peer Review subcommittee.
Pennsylvania Eye and Ear Surgery Center has contracted with a new anesthesia service as of April 15, 2024. This group will replace the current service and will be completing peer review for their own clinical staff based on Pennsylvania Eye and Ear Surgery Center's expectation and policy from the start of their contract. The Clinical Director will educate the new anesthesia group on the Peer Review policy, process, and timelines prior to the new service's start date. The Clinical Director will supervise the Peer Review process with the new group according to policy and procedures outlined above.
Effective as of the date that the Peer Review subcommittee meeting in the third quarter of 2024, Pennsylvania Eye and Ear Surgery Center will be up to date on all peer review for anesthesia providers working in the facility. The Clinical Director will manage the peer review process according to the quarterly schedule and will document results in the minutes of the Peer Review subcommittee and Board meetings.
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