551.22. Criteria for Performance of Ambulatory Surgery on Pediatric Patients
In addition to the criteria set forth at 551.21 (relating to criteria for ambulatory surgery), the following criteria shall apply to the performance of ambulatory surgery on children under 18 years of age. (2) The medical record shall include documentation that the child's primary care provider was notified by the surgeon in advance of the performance of a procedure in an ambulatory surgical facility and that an opinion was sought form the primary care provider regarding the appropriateness of the use of the facility for the proposed procedure. When such an opinion from the child's primary care provider is not obtainable, the medical record shall include documentation which explains why such an opinion could not be obtained.
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Observations:
Based on review of facility documents, medical record (MR), and interview with staff (EMP), it was determined the facility failed to notify the child's primary care physician (PCP) and seek an opinion regarding the appropriateness of performing the procedure in an ambulatory surgical facility (ASF) for three of three pediatric medical records reviewed.
Findings include:
On February 12, 2024, at approximately 11:00 AM, review of facility policy titled "Care of the Pediatric Patient" with a revised date of 6/2021, revealed that the policy failed to address the notification of the child's primary care physician (PCP). On February 12, 2024, at approximately 10:15 AM, review of MR2 revealed no documentation for the notification of the child's PCP. On February 12, 2024, review of MR3 revealed no confirmation that documentation to child's PCP was sent. On February 12, 2024, review of MR4 revealed no confirmation that documentation to child's PCP was sent. On February 12, 2024, at approximately 10:45 AM an interview with EMP1 confirmed MR2, MR3, and MR4 lacked appropriate documentation that the child's PCP was notified and an opinion sought as to the appropriateness of performing the procedure in an ASF.
| | Plan of Correction - To be completed: 03/29/2024
The deficiencies were reviewed by the Administrator, Medical Director, and the Clinical Director to address the identified deficiency. The Business Office Manager was informed as to the documentation which was deficient in the findings.
The Administrator, Medical Director and the Clinical Director, reviewed and updated the policy for "Care of the Pediatric Patient" (PC360). Current practices were reviewed and processes were updated.
The Medical Director and Clinical Director will review policy PC360, and provide education to the medical, allied health, and clinical staff.
The Business Office Manager will provide education and review policy PC360 with the business office staff.
Chart audits for pediatric patients will include at least five (5) charts per week, on-going, to ensure compliance. The Clinical Director and Peri-Anesthesia Nurse Manager will be responsible for performance of chart audits.
Results of chart audits will be reviewed and reported at the quarterly QAPI meetings.
If any or all parts of the policy for the "Care of the Pediatric Patient" are found to be deficient or undocumented, the Medical Director and/or Clinical Director will follow-up with the individual(s) and provide education and coaching.
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