Pennsylvania Department of Health
TRI-STATE SURGERY CENTER, LLC
Patient Care Inspection Results

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TRI-STATE SURGERY CENTER, LLC
Inspection Results For:

There are  34 surveys for this facility. Please select a date to view the survey results.

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TRI-STATE SURGERY CENTER, LLC - 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 October 2, 2023, at Tri-State Surgery Center. It was determined the facilitywas 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:


555.3 (d)(1-2) LICENSURE Requirements:State only Deficiency.
Granting of clinical privileges shall follow established policies and procedures in the bylaws or similar rules and regulations the procedures shall provide the following.
(1) Written record of the application, which includes the scope of privileges sought and granted. The delineation "clinical privileges"shall address the administration of anesthesia.
(2) A review, summarized on record with appropriate documentation of the qualifications of the applicant.

Observations:

Based on a review of facility documents, credential files (CF) and staff interview (EMP), it was determined that the facility failed to follow established policies and procedures for re-appointment as outlined in the Medical Staff Bylaws in eight of ten credential files reviewed(CF2, CF3, CF4, CF6, CF7, CF8, CF9, and CF10).

Findings include:

On October 2, 2023, a review of the Medical Staff Bylaws (Last Revised: 09/23/2019) "Section E- Reappointment Process: 3. At appropriate intervals, the Governing Board shall review all pertinent information required of or available on each Practitioner for the purpose of determining recommendations for reappointment to the staff and/or renewal or change of privileges for the ensuring reappointment. When non-reappointment or a change in privileges is recommended, the reason for such recommendation shall be stated and documented."

On October 2, 2023, a review of CF2 revealed that the clinician received a letter of reappointment signed by the Medical Director on Behalf of the Governing Body on May 31, 2023, and without formal approval by the Governing Board.

On October 2, 2023, a review of CF3 revealed that the clinician received a letter of reappointment signed by the Medical Director on Behalf of the Governing Body on December 1, 2022, without formal approval by the Governing Board.

On October 2, 2023, a review of CF4 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on July 11, 2023, without formal approval by the Governing Board.

On October 2, 2023, a review of CF6 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on November 28, 2022, without formal approval by the Governing Board.

On October 2, 2023, a review of CF7 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on October 13, 2022, without formal approval by the Governing Board.

On October 2, 2023, a review of CF8 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on May 26, 2023, without formal approval by the Governing Board.

On October 2, 2023, a review of CF9 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on November 30, 2021, without formal approval by the Governing Board.

On October 2, 2023, a review of CF10 revealed that the clinician received a letter of reappointment, signed by the Medical Director, on Behalf of the Governing Body on September 22, 2022, without formal approval by the Governing Board.

On October 2, 2023 at 12:00pm, EMP1confirmed the above findings.





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 Plan of Correction - To be completed: 12/31/2023

The Policies: "Credentialing of Medical Staff" and "Credentialing of Allied Health Professionals" have been changed to be consistent with the Medical Staff Bylaws. Policies will be presented to Patient Care Committee, Medical Executive Committee and Board of Managers for approval at the next regularly scheduled meetings. All reappointments will be audited by the Executive Director until 100% compliance is achieved for 2 consecutive months. Results will be reported up through the Board of Managers.
569.35 (7) LICENSURE General Safety Precautions:State only Deficiency.
569.35 General Safety Precautions
The following safety precautions shall be met:
(7) Only nonflammable agents may be present in a surgical suite.
Observations:


Based on observations and staff interview (EMP), it was determined the facility failed to follow general safety precautions by failing to ensure flammable agents were securely mounted in one of two surgical suites toured.

Findings include:

During a tour of the facility on October 2, 2023, at approximately 11:35 AM, two partially used two-ounce bottles of alcohol-based (62% ethanol) spray hand sanitizer were found unsecured on top of the anesthesia workstations in Operating Room (OR) #2.

During an interview at the time of the observation, EMP2 confirmed the above observations and confirmed that electrocautery is performed in this OR.













 Plan of Correction - To be completed: 12/31/2023

CRNAs will be educated during their next staff meeting that the approved personal hand sanitizers that they use at the hospital are prohibited from use at Tri-State Surgery Center. Hand sanitizer will continue to be made available via the wall mounted dispenser located near the anesthesia machine. Environmental Inspections will be conducted until 100% compliance is achieved for 2 consecutive months. Audit results will be reported up through the Board of Managers.

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