Pennsylvania Department of Health
OPHTHALMOLOGY AND SURGICAL INSTITUTE OF CENTRAL PENNSYLVANIA
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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OPHTHALMOLOGY AND SURGICAL INSTITUTE OF CENTRAL PENNSYLVANIA - 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 April 8, 2025, at Ophthalmology and Surgical Institute of Central PA. 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:

553.3 (8)(iii) LICENSURE Governing Body Responsibilities:

553.3 Governing Body responsibilities include:
(8) Establishing personnel policies and practices which adequately support
sound patient care to include, the following:
(iii) Personnel records shall include current information relative to periodic work performance evaluations.

Observations:

Based on review of facility documents, personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure that personnel records contained information relative to periodic work performance evaluations for four of ten personnel files reviewed (PF6, PF7, PF8, and PF9).

Findings include:

Review of "Performance Evaluation And Wage And Salary Guidelines" Policy with a most recent review date of January 8, 2024, states "It is the policy of OSI of Central Pennsylvania and the Clinical Director on a quarterly basis, assess each clinical employee's quality and quantity of work performance, attendance, and attitude on the Employee Performance Evaluation form and meet with each employee and, through discussion review performance ..."

Review of PF6 revealed the file did not contain evidence of a performance evaluation for 2024.

Review of PF7 revealed the file did not contain evidence of a performance evaluation for 2024.

Review of PF8 revealed the file did not contain evidence of a performance evaluation for 2024.

Review of PF9 revealed the file did not contain evidence of a performance evaluation for 2024.

Interview with EMP1 on April 8, 2025, at 12:00 PM confirmed that there were no evaluations in the personnel files as stated above.

Plan of Correction - To be completed: 05/02/2025

t is the responsibility of the Clinical Director to routinely evaluate the facility medical/reception staff.
The evaluations for the staff listed in the DOH deficiency will be completed no later than May 2, 2025.
The current staff evaluation policy listed in the facility Admin Manual and HR Manual has been updated to reflect the change from quarterly to annual employee evaluations which will be based on the employee anniversary date.
To ensure no further lapse in evaluations, the Clinical Director will keep a list of all employees including their anniversary dates. Once the annual eval is completed, it will be documented with the date on the spreadsheet.
Anniversary dates will be added to CD's Outlook Calendar to pop up with a reminder to ensure compliance.
This will ensure timely evals and will serve as a record should the CD not be available for subsequent evals.
Should that happen, the evals will fall under the responsibility of the current Medical Director.

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