Governing Body responsibilities include:
(1) Conforming to all applicable Federal, State, and local laws.
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).
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.