Nursing Investigation Results -

Pennsylvania Department of Health
COMMUNITY SURGERY & LASER CENTER LLC
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
COMMUNITY SURGERY & LASER CENTER LLC
Inspection Results For:

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COMMUNITY SURGERY & LASER CENTER LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a full State Licensure survey conducted on January 30, 2020, at Community Surgery & Laser 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:


Initial comments:

This report is the result of a full State Licensure survey conducted on January 30, 2020, at Community Surgery & Laser Center. It was determined the facility was in compliance with the requirements of 35 P.S. 448.809 (b).






 Plan of Correction:


553.3 (1) LICENSURE Governing Body Responsibilities:State only Deficiency.
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.

Observations:

Based on review of facility documentation and employee interview (EMP), it was determined that the facility failed to conform to all applicable State laws and regulations.

Community Surgery & Laser Center was not in compliance with the following State law:

Act 70 Adult Protective Services Chapter 3 Section 301(a)(5) "The department shall establish, by regulation, minimum standards of training and experience that agencies funded by the department shall follow in the selection and assignment of staff for the provision of protective services. The standards shall require agencies to collaborate with adults, their families and advocates, and the standards shall be included in developing and delivering training."

This was not met as evidenced by:

Based on review of facility documentation, and personnel files (PF), as well as employee interview (EMP), it was determined that the facility did not provide education for Act 70 as required based on Act 70 Adult Protective Services Chapter 3 Section 301(a)(5) for eight of eight PF (PF1, PF2, PF3, PF4, PF5, PF6, PF7, and PF8).

Findings include:

1. Review, at approximately 1:45 PM on January 20, 2020, of "C8.16 ACT 70 Mandatory ABUSE/NEGLECT Reporting," no date, revealed, "... The Community Surgery and Laser Center will report any suspected abuse, exploitation, abandonment, or neglect per the ACT 70 guidelines. ... Further instructions are outlined in ACT 70 of 2010 on following [sic] page. ..."

2. Review, from approximately 12:00 PM through 12:25 PM on January 30, 2020, of PF1, PF2, PF3, PF4, PF5, PF6, PF7, and PF8, revealed no documentation that Act 70 training had been provided.

At approximately 1:06 PM on January 30, 2020, when asked for verification of staff education on Act 70, EMP1 stated, "... I did not give any [education]. ..."







 Plan of Correction - To be completed: 04/03/2020

All current employees at the ASC will receive ACT 70 training/in-service explaining the ACT 70 and our policy. Training will be conducted by the Center Director. Employees will sign a document indicating they received and understand the training. All new hires will complete the training as part of their required on boarding process. Training will be provided by Center Director or designee. The training power point and policy will be placed in the Patient Safety Binder in the break room for employees to rereview when they so desire. A weekly audit will be performed for the next 90 days to review any new hire files for required ASC ACT 70 training by Center Director and designee. A special Board Meeting/PQI meeting will be held to review deficiencies, POC, and perform a root cause analysis. POC will be implemented by Center Director.


553.3 (8)(ii) LICENSURE Governing Body Responsibilities:State only Deficiency.
553.3 Governing Body responsibilities include:
(8) Establishing personnel policies and practices which adequately support
sound patient care to include, the following:
(ii) Applications for positions requiring a licensed person shall be hired only after obtaining verification of their licenses, records of education, and written references.


Observations:

Based on review of personnel files (PF) and employee interviews (EMP), it was determined that the facility failed to obtain a minimum of two written references for positions requiring a licensed person for three of three new hires (PF1, PF2, and PF3).

Findings Include:

Review, at approximately 1:30 PM on January 30, 2020, of "C8.6 Employee Files," dated April 2019, revealed, "... PROCEDURE/GUIDELINES: The following information will maintained [sic] in each employee file: ... Job Application or Resume and one written reference; ..."

1. At approximately 12:15 PM on January 30, 2020, review of PF1, revealed one written reference prior to being hired.

2. At approximately 12:18 PM on January 30, 2020, review of PF2, revealed one written reference prior to being hired.

3. At approximately 12:23 PM on January 30, 2020, review of PF3, revealed one written reference prior to being hired.

At approximately 1:14 PM on January 30, 2020, when asked if the personnel files reviewed [PF1, PF2, and PF3] contained more than one written reference, EMP1 stated, "No. ... I changed the policy to one reference. ..."






 Plan of Correction - To be completed: 04/03/2020

Policy will be updated by Center Director to indicate that all new hires at the ASC will have two written references in their file before they can work in the ASC. A second written reference will be obtained from the current three employees that do not possess them in their files by February 28th, 2020. A weekly audit will be performed for the next 90 days to review any new hire files for two written references by Center Director and designee. A special board meeting/PQI meeting will be held to review deficiencies, POC, and perform a root cause analysis. Center Director will be responsible for implementing the acceptable POC.



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