Nursing Investigation Results -

Pennsylvania Department of Health
BRANDYWINE SURGERY CENTER
Patient Care Inspection Results

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BRANDYWINE SURGERY CENTER
Inspection Results For:

There are  33 surveys for this facility. Please select a date to view the survey results.

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BRANDYWINE SURGERY CENTER - 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 March 11, 2020, at Brandywine Surgery Center. 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:


51.3 (a) LICENSURE Notification:State only Deficiency.
51.3 Notification

(a) A health care facility shall notify the Department in writing at least 60 days prior to the intended
commencement of a health care service which has not been previously provided at that facility.


Observations:
Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to notify the "Department" 60 days prior to the initiation of a new service (Pediatrics) for one of one medical record reviewed (MR24).

Findings include:

Review of the facility's policy "Brandywine Surgery Center" last reviewed February 2016 revealed "There will be an organized medical staff which is accountable to the governing body and which has a responsibility for the quality of medical care provided to patients and for the ethical conduct and professional practice of its members and other practitioners who have been granted clinical privileges in Brandywine Surgery Center."
Review of facility document "Brandywine Surgery Center Job Description-Administrator" not dated revealed " The Administrator shall have the function of overseeing the coordination of the activities at Brandywine Surgery Center under the supervision of the Medical Director. This shall specifically include "...3. Recredential of all medical staff and recommendations to governing body on reappointment on a bi-annual basis."

Review on March 11, 2020 of MR24, revealed a 17 year-old- patient, with a surgical procedure performed on July 10, 2019, for Rhinoplasty (nose surgery).

An interview conducted on March 11, 2020, with EMP1 confirmed MR24 was a 17 year-old pediatric. Further interview confirmed the facility did not notify the "Department" of the new pediatric service line. EMP1 stated "It was just one patient". In addition, EMP1 also confirmed that the facility was never provided approval to provide services to pediatric patients. Further interview confirmed CF1, a physician/surgeon was not granted privileges to perform pediatric surgery in the center.

Cross Reference:
555.3(d)(1): Requirements








 Plan of Correction - To be completed: 06/01/2020

Brandywine Surgery Center will correct this deficiency by notifying the Department of Health in writing at least 60 days prior to the initiation of any new health care service(pediatrics) which has not been previously provided at the facility.
A letter will be emailed to the Department of Health asking for an Occupancy Survey for Pediatric Surgery. No Pediatric surgeries will be performed until this has been obtained. The administrator shall have the function of overseeing the coordination of the activities at Brandywine Surgery Center under the supervision of the Medical Director. The physician/surgeon will be re-credentialed to perform pediatric surgery in the center. Approval must be given by the Governing Body before any pediatric surgery can be conducted.
The Governing Body will be responsible to oversee that the Department of Health will be notified in writing 60 days prior to initiation of a new service. The Administrator will educate the Governing Body, as evidenced in Governing body meeting minutes, about the above requirements for notification of Occupancy survey as required in the regulations. The Quality Assurance Committee will meet to confirm the above measures have been completed. The Administrator/CEO is responsible for this Plan of Correction completion by 06/01/2020.

553.31 (a) LICENSURE Administrative responsibilities:State only Deficiency.
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 facility documents, personnel files (PF) and interview with staff (EMP), it was determined the Governing Body failed to ensure that a full time person in charge was appointed who had the authority and responsibility for the operation of the Ambulatory Surgery Center (ASC) at all times.

Findings include:

Review of PF1, for EMP1 "Job Description-Administrator" not dated and signed by the administrator for each job category revealed "Administrator: The Administrator shall have the function of overseeing the coordination of activities at Brandywine Surgery Center under the supervision of the Medical Director..Circulating Nurse: The circulating nurse has the responsibility of patient safety from admission to recovery room. Recovery Nurse: The recovery nurse has the responsibility of patient safety from entrance to recovery room until discharge."

Review on March 11, 2020, of facility document Surgery Log February 2020 revealed EMP1, the administrator performed as a circulating nurse on February 10, 2020, and February 14, 2020.

Review on March 11, 2020, of facility document Surgery Log December 2019 revealed EMP1, the administrator performed as a circulating nurse on December 30, 2019.

An interview conducted on March 11, 2020, at 1:05 PM with EMP1 and EMP2 confirmed the Administrator was expected to perform as the Circulating Nurse in the Operating Room to support staffing needs while simultaneously functioning in the role as the Administrator overseeing the day to day activities of the ASC at all times. EMP2 stated "Obviously we are not compliant with the regulation as the Administrator is expected to help out with surgical cases when needed."





 Plan of Correction - To be completed: 04/10/2020

The Brandywine Surgery Center will correct this deficiency by appointing a full time administrator who has authority and responsibility for the operation of the surgery center at all times. The description of the Administrator's duties which includes qualifications,authority, responsibilities and duties of the person in charge will be reviewed by the Governing Body. When approved the Administrators Responsibilities statement will be adopted and properly updated with month date and year.
The Governing Body will assure ongoing observance of this policy. The administrator will not assist in the operating room or recovery room effective immediately. The Quality Assurance committee will assure the above measures are complete and ongoing.
The CEO/Administrator will attest to completion by 4/10/2020.
555.3 (d)(1) LICENSURE Requirements:State only Deficiency.
555.3 Requirements for membership and privileges.

(d) Granting of clinical privileges shall follow established policies and procedures in the bylaws or similar rules and regulations the procedures shall provide the following.
(1) Written record of the application, which includes the scope of
privileges sought and granted. The delineation "clinical privileges" shall address the administration of anesthesia.

Observations:

Based on a review of facility policy, document, credential files (CF), and interview with staff (EMP), it was determined the facility failed to obtain a written application and approved delineation of privileges for one of one credential files reviewed (CF1).

Findings include:

Review of the facility's policy "Brandywine Surgery Center Medical Staff" last reviewed February 2016 revealed "There will be an organized medical staff which is accountable to the governing body and which has a responsibility for the quality of medical care provided to patients and for the ethical conduct and professional practice of its members and other practitioners who have been granted clinical privileges in Brandywine Surgery Center. ...Requirements: 4. Granting of clinical privileges shall follow the established policies and procedures outlined in the Governance policy Article III. These procedures require written of: a. Application and a review of the appropriate documentation by the governing body."

Review of facility document "Brandywine Surgery Center Job Description-Administrator" not dated revealed " The Administrator shall have the function of overseeing the coordination of the activities at Brandywine Surgery Center under the supervision of the Medical Director. This shall specifically include "...3. Recredential of all medical staff and recommendations to governing body on reappointment on a bi-annual basis."

1. Review on March 11, 2020, of CF1, a physican revealed no evidence of documentation of an application for the reappointment period of February 7, 2019, through February 6, 2021, for CF1.

An interview conducted on March 11, 2020, at 1:05 PM with EMP1 and EMP2 confirmed that a written application for reappointment of CF1, was not completed nor had it been a presented to the governing body prior to the reappointment of CF1. EMP2 confirmed the facility was not compliant with state regulations and the facility's policy.

2. Review on March 11, 2020, of CF1, a physician revealed the following privileges were requested on March 6, (no year transcribed): Full Rejuvenation, Body Sculpting, Nose Surgery, Liposuction." Further review of the privileges of CF1 revealed no evidence of documentation that the privileges requested on March 6 were approved. In addition, the privileges requested on March 6, did not contain the year of when the privileges were requested.

An interview conducted on March 11, 2020, with EMP1 and EMP2 confirmed no evidence of documentation of the year the privileges were requested for the reappointment period of February 7, 2019, to February 6, 2020, EMP1 and EMP2 confirmed the request privledges did not contain the year the privileges were requested and the facility failed to follow their policy for appropriate documentation.


3. Review on March 11, 2020, of CF1, a physician revealed the following privileges were request on March 6, (no year transcribed) : Facial Rejuvenation, Body Sculpting, Nose Surgery, Liposuction. Further review revealed no evidence of documentation that CF1 requested and were approved privileges for a Abdominoplasty (tummy tuck) surgical procedure for the reappointment period of February 7, 2019, to February 6, 2021.

Review of MR1 revealed an Abdominoplasty surgical procedure on November 25, 2019, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR2 revealed an Abdominoplasty surgical procedure on November 26, 2019, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR3 revealed an Abdominoplasty surgical procedure on December 18, 2019, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR4 revealed an Abdominoplasty surgical procedure on December 18, 2019, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR5 revealed an Abdominoplasty surgical procedure on January 22, 2020, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR6 revealed a Mini Abdominoplasty surgical procedure on January 22, 2020, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR7 revealed an Abdominoplasty surgical procedure on January 30, 2020, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR8 revealed an Abdominoplasty surgical procedure on February 6, 2020, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR9 revealed an Abdominoplasty surgical procedure on February 19, 2020, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR10 revealed an Abdominoplasty surgical procedure on February 26, 2020, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR11 revealed an Abdominoplasty surgical procedure on Feburary 26, 2020, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

Review of MR12 revealed an Abdominoplasty surgical procedure on February 27, 2020, performed by CF1, a physician. The privileges requested on March 6 (no year transcribed), by CF1 did not reveal a request for an Abdominoplasty surgical procedure.

An interview conducted on March 11, 2020, at 1:17 PM with EMP1 and EMP2 confirmed CF1 was not privileged to perform the Abdominoplasty procedure for MR1 through MR12. Further interview confirmed the delineation of privileges for CF1 was incomplete and did not have the required documentation for performing the Abdominoplasty procedure at the center.

Cross Reference:
51.3(a): Notification






























 Plan of Correction - To be completed: 04/27/2020

The Brandywine Surgery Center will correct this deficiency by the following:

An application form will be created by the Medical staff and approved by the Governing Body for the credentialing package. This application will be sent to the physician/surgeon identified in the deficiency as not having the credentialing application and the physician/surgeon will be re-credentialed.

The Quality Assurance Committee and Medical Director will review the file of the physician/surgeon identified in the deficiency for the new completed application form and appointment-reappointment letter.

The Governing Body will review and approve the credentialing packet of the physician/surgeon identified in the deficiency to assure compliance with the facility's policy and state regulations.
The physician/surgeon identified in the deficiency has requested the addition of the privilege for Abdominoplasty(tummy tuck). The request of the addition of the privilege will be presented to the Quality Committee and Governing Body for review and approval.
Upon approval the physician/surgeon will be re-credentialed.
Administrator/CEO will attest to completion by 04/27/2020.

An approved Delineation of Privilege's form will be developed that identifies all procedures performed by the facility's medical staff.
The Delineation of Privileges form will be revised and approved by the Governing Body to include privileges requested and privileges approved with the signature of the Medical staff for approval.

The Administrator will revise the present credential file checklist and review the facility's credentialing policy. The Administrator and Medical Director will review the credentialing packet for completeness of all required forms and complete and sign the credential file checklist prior to the presentation of the credentialing packet to the Governing Body Committee.

The Quality Assurance Committee and Governing Body Committee will confirm all documents required for credentialing are signed, dated and are in compliance with the facility policy and state regulations.

The review and auditing process for credential files will be documented in the Quality Assurance and Governing Body Meeting minutes annually.
Administrator/CEO will attest to completion by 4/27/2020



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