Pennsylvania Department of Health
YORK ADAMS PAIN SPECIALISTS, P.C.
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 25 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


YORK ADAMS PAIN SPECIALISTS, P.C. - 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 November 9, 2023, at York Adams Pain Specialists. 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:

563.12 (2) LICENSURE Form and Content of Record:

563.12 Form and content of record

The ASF shall maintain a separate medical
record for each patient. Each record shall be accurate, legible and
promptly completed. Patient medicals shall be constructed to stand alone and be easily identified as ASF records. Medical records must include at least the following:
(2) Pertinent medical history and results of physical examination

Observations:

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that 2 out of 10 medical records had documented physical examinations prior to receiving services (MR1, and MR2).

Findings include:

On November 6, 2023, at approximately 12:30 PM, a review of facility policy titled "Pre-Procedure Phase" with a revision date of September 2014, revealed "... all patients will have a recent history and physical examination (no more than 30 days prior), either by their primary care physician or by the ASF physician, prior to any procedure ..."

Review of medical records conducted on November 6, 2023, at approximately 11:00 AM revealed MR1 did not have a physical examination documented prior to the operative procedure.

Review of MR2 on November 6, 2023, revealed that MR2 did not have a physical examination documented prior to the operative procedure.

An interview with EMP1 on November 6, 2023, at approximately 12:30 PM confirmed the above findings that MR1 and MR2 did not have documentation of a physical exam being completed.

Plan of Correction - To be completed: 01/31/2024

In order to ensure appropriate and complete documentation of history and physical exam on all charts, our medical record chart review lists were updated on 11/16/23 to clarify all required elements. A review of our H & P policy, all required elements of H & P's and our updated forms will be completed by all of the staff and provider by December 15th, 2023. One month following completion of education, a focused chart review of 10 random charts will be completed by the Director of Nursing to ensure compliance. Our medical records reviewer will continue to review 100% of all charts.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement