Pennsylvania Department of Health
EYNON SURGERY 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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EYNON SURGERY CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced onsite special monitoring survey conducted on August 29, 2023 and completed offsite on September 8, 2023 at Eynon Surgery 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:

51.3 (c) LICENSURE Notification:

51.3 Notification

(c) A health care facility shall provide similar notice at least 60 days prior to the effective date it
intends to cease providing an existing health care service or reduce it licensed bed complement.

Observations:

Based on review of facility documents and staff interview (EMP), it was determined the Eynon Surgery Center LLC failed to notify the Department of Health (Department) in writing at least 60 days prior to the effective date the faciltiy intended to cease services.

Findings include:

Email communication dated March 1, 2023, from EMP2 revealed the owners of the Eynon Surgery Center were attempting to sell the surgery center, as two of the physicians had retired.

Review on August 9, 2023 of the Department correspondence revealed a notification letter from Eynon Surgery Center dated August 8, 2023, noting the facility was ceasing operations effective immediately.

Interview on August 29, 2023 at 0900 with EMP1 confirmed the above findings.

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

553.3 (3) LICENSURE Governing Body Responsibilities:

553.3
Governing Body responsibilities include:
(3) Assuring the facilities and personnel are adequate and appropriate to carry out the goals and objectives.

Observations:

Based on review of the Department of Health's (Department) database, a tour of the facility and staff interview (EMP), it was determined the facility failed to maintain and operate safely and efficiently in order to provide patient services.

Findings include:

Review on August 23, 2023, of the Department's database revealed the surgery center remained open, as they were seeking a buyer for the surgery center.

A tour of the facility on August 29, 2023, at approximately 0910 revealed five patient stretchers in the preop/postoperative area covered with sheets. Monitors were at each bedside. Cabinets behind the nursing desk contained patient care supplies. There were three procedure rooms, A, B and C. Procedure Room A was 50% full of packed boxes. The room could not be easily set up for a procedure at the time of the tour.

Procedure Room B was completely filled with boxes, a locked crash cart, and a small running refrigerator. These could not be accessed, as there were stacks of boxes filling the room. The was an Automated External Defibrillator (AED) on top of the crash cart and a suction canister. The room could not be easily set up for a procedure at the time of the tour.

Procedure Room C was an unfinished room. There was a C-arm in this room.

Interview with EMP1 on August 29, 2023 at approximately 0920, confirmed the findings noted above. EMP1 revealed s/he was the last remaining staff person at the facility with his/her last day of employment on August 31, 2023.

Cross reference with 553.31(b)

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

555.1 LICENSURE MEDICAL STAFF PRINCIPLE:

555.1 Principle

There shall be an organized medical staff which is accountable to the governing body and which has 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 the ASF.

Observations:

Based on review of the Department of Health's (Department) database and staff interview (EMP), it was determined the facility failed to maintain a Medical Director on staff.

Findings include:

Review on August 23, 2023, of the Department's database revealed the surgery center remained open, as they were seeking a buyer for the surgery center.

Interview with EMP1 on August 29, 2023 at approximately 0920, revealed s/he was the last remaining staff person at the facility with his/her last day of employment on August 31, 2023.
EMP1 revealed there was no Medical Director. EMP1 did not have access to the operating room log. EMP1 completed the last patient billing in February 2023. EMP1 revealed the last time procedures were performed was in February 2023.

Cross reference 553.4(h)

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

559.1 LICENSURE Nursing Department:

559.1 Nursing Department

The ASF shall have an organized nursing department under the supervision of a registered nurse who has responsibility and accountability for the Nursing Service.

Observations:

Based on review of the Department of Health's (Department) database and staff interview (EMP), it was determined the facility failed to maintain a Director of Nursing and nursing staff in order to provide patient care.

Findings include:

Review on August 23, 2023, of the Department's database revealed the surgery center remained open, as they were seeking a buyer for the surgery center.

Interview with EMP1 on August 29, 2023 at approximately 0920, revealed s/he was the last remaining staff person at the facility with his/her last day of employment on August 31, 2023.
EMP1 revealed there was no Director of Nursing and all nursing staff had been furloughed.

Cross reference 559.2

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

563.6 (c) LICENSURE Preservation of Medical Records:

563.6 Preservation of medical records

(c) If an ASF discontinues operation, it shall make known to the
Department where its records are stored. Records are to be stored in a
facility offering retrieval services for at least 5 years after the closure
date. Prior to destruction, public notice shall be made to permit former
patients or their representatives to claim their own records. Public notice
shall be in at least two forms, legal notice and display advertisement in a
local newspaper of general circulation.

Observations:

Based on review of email communications, it was determined the Eynon Surgery Center failed to provide the Department of Health (Department) with written documentation on the storage and retrieval of medical records when the surgery center discontinued operation.

Findings include:

Review on September 8, 2023, of email communication with the Eynon Surgery Center revealed closure information was requested by the Department. This was to include where the patient medical records would be stored. The information was requested August 10, 2023, following the notification that the facility was closing August 8, 2023, August 29, 2023, and again on August 31, 2023. The information was not provided.

Cross reference:
51.3(c) Notification

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

567.41 LICENSURE MAINTENANCE SERVICE - Principle:

567.41 Principle

The ASF shall be equipped, operated and maintained to sustain its
safe and sanitary characteristics and to minimize health hazards in the ASF
for the protection of patients and employes.

Observations:

Based on review of facility documents, observation and interview with staff (EMP), it was determined the Eynon Surgery Center was not equipped, operated and maintained to sustain safe and sanitary characteristics.

Findings include:

Telephone interview with OTH1 on March 2, 2023, revealed the Eynon Ambulatory Surgery Center building had structural concerns. The flat roof required repair, and there was a crack in the foundation of the building.

On arrival at the Eynon Surgery Center on August 29, 2023, at 0850, the outside of the building and parking lot were overgrown with grass and weeds. The asphalt was cracked, crumbling and had potholes. The building appeared abandoned.

Tour on August 29, 2023, at 0910 was conducted with EMP1, the only individual working at the ASC. Observation of the waiting room/admission area revealed the majority of the facility files and supplies were boxed up. The entire area smelled musty.

Tour of the pre/postoperative area revealed stretchers covered with sheets. The area was set up for patient care. There were supplies in the cabinets. For example, there were intravenous fluids, syringes, gloves, and glucometer supplies. There were three procedure rooms, A, B and C.

Procedure Room A was 50% full of packed boxes. The room could not be easily set up for a procedure at the time of the tour.

Procedure Room B was completely filled with packed boxes, a locked crash cart, and a small running refrigerator. The crash cart and refrigerator could not be accessed due to the boxes. There was a check list on the top of the crash cart. Facility documentation revealed the last time staff accessed and checked the cart for expired items was March 10, 2023. The room could not be easily set up for a procedure at the time of the tour.

Procedure Room C was an unfinished room. There was a C-arm in this room awaiting removal.

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

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