Nursing Investigation Results -

Pennsylvania Department of Health
CHILDREN'S DENTAL SURGERY OF MALVERN
Patient Care Inspection Results

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CHILDREN'S DENTAL SURGERY OF MALVERN
Inspection Results For:

There are  15 surveys for this facility. Please select a date to view the survey results.

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CHILDREN'S DENTAL SURGERY OF MALVERN - 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 January 29, 2020, at Children's Dental Surgery of Malvern. 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:


553.12 (b)(4) LICENSURE Implementation:State only Deficiency.
553.12
(b) The following are the minimal provisions for the patient's bill of
rights:
(4) A patient has the right to have records pertaining to his medical care
treated as confidential except as otherwise provided by law or third party contractual arrangements.

Observations:
Based on observation tour, review of facility policy, documentation, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the personal health information (PHI) pertaining to the medical care for three of three medical records reviewed was treated in a confidential manner and secured at the registrar's desk (MR1 MR2 and MR3).

Findings include:

Review of facility policy "Bylaws of the Medical Staff of Children's Dental Surgery" last revised November 11, 2018, revealed " 3. Confidentiality of Information: A. Information submitted, collected or prepared by any representative of the Center or third party for the purpose of evaluating, monitoring or improving the quality and efficiency of patient care services; determining that services are professionally indicated or were performed in compliance with the applicable standard of care; or related to any of the activities set forth in these Bylaws shall be privileges and confidential and so maintained by the Center."

Review of facility policy " Identification of the Patient" last revised October 18, 2018, revealed " 1. Reception Area: a. Upon greeting the patient, Center staff confirms the patient's name, social security number, date of birth and various elements."

An observation tour of the facility conducted on January 29, 2020, at 4:00 PM of the reception area of the registrar desk revealed two unlocked drawers of patient personal health information obtained by the receptionist which contained the following information:

Review of MR1, PHI revealed the first and last name of the patient, personal address, telephone number, date of surgical procedure date of January 30, 2020 and the name of the surgeon performing the procedure, CF1.

Review of MR2, PHI revealed the first and last name of the patient, personal address, telephone number, date of surgical procedure date of January 30, 2020 and the name of the surgeon performing the procedure, CF2.

Review of MR3, PHI revealed the first and last name of the patient, personal address, telephone number, date of surgical procedure date of January 30, 2020 and the name of the surgeon performing the procedure, CF2.

An interview conducted on January 29, 2020, at 5:00 PM with EMP2 confirmed that the unlocked opened drawers at the receptionist's desk contained personal health information for MR1, MR2 and MR3 that was not treated in a confidential manner and secured. EMP2 stated " I will need to inservice the staff that sits in this area about securing patients PHI."



 Plan of Correction - To be completed: 06/01/2020

At the end of each business day the front desk staff will lock all patient records in the business office before leaving at the end of each worked shift

Staff will be required to attend a meeting that will take place the week of 3/2/2020. Staff will be required to sign in that they participated in an educational training provided by the administrator and director of nursing about patient confidentiality about topics including:
1. Elements of HIPPA
2. Patient Rights
3. Educate staff about the new internal process for securing patient records at the end of each business day.

At the end of each business day the front desk staff will lock all patient records in the business office. After this task is complete an attestation sheet will be signed by the front desk staff employee responsible for securing patient charts. This attestation log we be maintained including the staff members name and date that they secured patient records.

The Director of Nursing and Administrator will be responsible for sustaining patient confidentiality through weekly audits checking that patient charts were secured at the end of each business day. The administrator and DON will monitor this process until 100% compliance is sustained by 6/1/2020. Compliance of weekly audits will be presented to the quality committee for review.

The corrective action will be complete 6/1/2020

555.3 (d)(2) LICENSURE Requirements:State only Deficiency.
555.3 Requirements for membership and privileges.

(d) Granting of clinical privileges shall follow established policies and procedures in the bylaws or similar rules and regulations the procedures shall provide the following.
(2) A review, summarized on record with appropriate documentation of the qualifications of the applicant.



Observations:

Based on review of facility Bylaws, policies, credential files (CF), and interview with staff (EMP), it was determined the facility failed to follow adopted credentialing practices as outlined in the Medical Staff Bylaws for two of two credential files reviewed (CF1 and CF2).

Findings include:

Review of facility Bylaws of the "Medical Staff of Children's Dental Surgery" last revised September 11, 2018, revealed "DEFINITIONS-Clinical Privileges or Privileges- means the permission granted by the Board to a practitioner to render specific diagnostic and therapeutic medical or surgical services at the Center within defined limits consistent with the practitioner's scope of practice or training. ...6. Initial Appointment, Reappointment, and Temporary Privileges" revealed "Temporary privileges may be granted after a complete application has been presented to the Medical Director, and the Medical Director has determined that he/she will make a positive recommendation regarding the applicant to the MAB and the Board. ...Temporary privileges shall be granted for a maximum term of ninety (90 days),,,"

Review of facility policy "Quality Assessment Plan" last dated September 11, 2018, revealed " c. Actions: The Medical Advisory Board (MAB) shall identify trends, important problems and concerns and recommend to the Governing Body that particular actions be taken to address these matters. These actions may include without limitations:...(a) Revising certain policies/procedures or implementing new policies and/or procedures...(d) revising a practitioner's privileges."


1). Review of facility policy "Credentialing" last review/revised November 15, 2017, revealed "7) The MAB approves Medical Staff appointment and reappointment then submits the information to the Governing Body to review. 5)The Governing Body reviews the MAB's determinations on initial appointments and reappointments to the Center's Medical Staff. ...The Medical Director has the discretion to approve appointments for temporary admitting privileges at the Center in accord with the Bylaws and related materials. 9) Temporary privileges are limited to a 6 month period. 10) Initial appointment and reappointment to the Medical Staff shall not exceed a two-year period."

Review of facility policy "Credentialing" last review/revised November 15, 2017, revealed "7) The MAB approves Medical Staff appointment and reappointment then submits the information to the Governing Body to review. 5)The Governing Body reviews the MAB's determinations on initial appointments and reappointments to the Center's Medical Staff. ...The Medical Director has the discretion to approve appointments for temporary admitting privileges at the Center in accord with the Bylaws and related materials. 9) Temporary privileges are limited to a 90 day period. 10) Initial appointment and reappointment to the Medical Staff shall not exceed a two-year period."

An interview conducted on January 29, 2020, at 4:00 PM confirmed that the facility's "Credentialing" policy language of Temporary Privileges granted for 6 months was an archive policy, received by the survey team from EMP1 at 1: 40 PM. Further interview confirmed the facility's "Credentialing" policy last reviewed on November 15, 2017, received by the survey team at 4:00 PM, sent by EMP4 with temporary privileges limited to a 90 day period was the current policy for the facility.


2). Review of CF1, dentist revealed "Children's Surgery Center, LLC Malvern Board Approvals: CF1 Temporary Privileges granted and approved as per the request on April 25, 2019. Further review revealed Permanent Privileges were granted and approved on October 31, 2019, by the Medical Director and granted and approved by the President on November 8, 2019.

Review of CF2, anesthesiologist revealed "Children's Surgery Center, LLC Malvern Board Approvals: CF2 Temporary Privileges granted and approved as per the request July 1, 2019. Further review revealed Permanent Privileges were granted and approved on January 3, 2020, by the Medical Director and granted and approved by the President on January 23, 2020.

An interview conducted on January 29, 2020, at 4:50 PM with EMP1 confirmed the facility had failed to maintain the granting and approving of privileges of CF1 and CF2 in accordance with the facility's Medical Staff Bylaws. EMP1 confirmed the time frame between when the temporary privileges ended and the permanent privileges were approved for CF1 and CF2 had not been approved by the MAB. Further interview confirmed that the facility continued to allow CF1 and CF2 to perform surgical procedures during this time period when the privileges were not approved.















 Plan of Correction - To be completed: 06/10/2020

Policy Q102: Credentialing, has been reviewed and updated to include new review date of 2/1/2020. This policy will be approved by the Quality Improvement & Performance committee at the next scheduled meeting March 17, 2020.

The administrator for Children's Dental Surgery will perform a monthly audit of all provider files to ensure all providers have current privileges to practice. The administrator will submit any providers who have temporary privileges expiring to the medical director and president within 30 days of expiration to ensure all providers are given permanent privileges prior to their 6 month temporary privileges expiring.
All permanent privileges granted to providers will be reviewed and approved by the Quality Improvement & Performance Committee on a quarterly basis.

The administrator will create a credentialing log that will be completed for each newly credentialed employee. This log will include the date the provider is given temporary privileges, when they are due for permanent privileges, and the date that permanent privileges are granted.

Administrator will present information from credentialing spreadsheet to the Quality Improvement & Performance Committee each quarter to ensure that there is 100% compliance. The spreadsheet will be completed monthly for a total of 6 months to ensure compliance, then quarterly thereafter to ensure all providers are granted permanent privileges within 6 months.

The Administrator will be responsible for this POC.


555.22 (e) LICENSURE Surgical Services - Preoperative:State only Deficiency.
555.22 Pre-operative Care

(e) Prior to the administration of anesthesia, it is the responsibility of the primary operating surgeon and the person administrating anesthesia to properly identify the patient and the procedure to be performed and to document this identification in the patient's medical record. This procedure shall be in written policies designating the mechanism to be used to identify each surgical patient.
Observations:
Based on review of facility policy, medical record (MR) and interview with staff (EMP), it was determined the facility failed to ensure the surgeon and or the anesthesia provider documented identifying the patient according to facility policy prior to the administration of anesthesia for three of three medical records reviewed (MR1, MR2 and MR3).

Findings include:

Review of facility policy "Identification of the Patient" last revised October 18, 2018, revealed "Before the patient is taken to the Operating Room (OR) Suite, clinical staff and/or anesthesia personnel will ask the patient or family for their name and the procedure to be performed. This information is checked along with the information on the patient chart. The patient's ID band is checked and the patient/parent is asked to verify the correct procedure. The patient is also identified with their parent if a minor child by the performing surgeon."

Review of MR1 admitted on January 7, 2020, for an oral rehab procedure performed from 12:52 PM- 2:05 PM revealed no evidence of documentation that MR1 was identified by the surgeon and or anesthesia provider prior to the administration of anesthesia.

Review of MR2 admitted on August 22, 2019, for an oral rehab procedure performed from 12:18 PM -2:52 PM revealed MR2 was identifed by the provider at 1:15 PM. Further review revealed no evidence of documentation that the surgeon and or the anesthesia provider identified MR2 prior to the administration of anesthesia.

Review of MR3 admitted on January 2, 2020, for an oral rehab procedure performed from 7:30 AM -9: 07 AM revealed MR3 was identified by the provider at 8:05 AM. Further review revealed no evidence of documentation that the surgeon and or the anesthesia provider identified MR3 prior to the administration of anesthesia.

An interview conducted on January 29, 2020, at 3:30 PM with EMP1 and EMP2 confirmed that MR1 contained no evidence of documentation that the surgeon and or the anesthesia provider identifed the patient prior to the administration of anesthesia. Further interview confirmed MR2 and MR3 did not contain evidence of documentation that the surgeon and or the anesthesia provider identified MR2 and MR3 prior to the administration of anesthesia for the procedures performed.












 Plan of Correction - To be completed: 06/11/2020

Children's Dental Surgery of Malvern will require the surgeon and anesthesiologist to verify the identify of each patient prior to administration of anesthesia or surgical services as outlined in policy C101: Identification of the patient.

Each surgeon and anesthesiologist will verify patients name, DOB, and procedure with both patient and parent while in the pre-operative area. This information will be checked along with the patient chart and patient ID band to ensure all providers are in compliance with Policy C101: Identification of the patient.

Identification of the patient shall take place with the parent/legal guardian in the preoperative area at the time of informed consent. This attestation is present on both the oral rehab consent and anesthesia consent. The dentist and anesthesiologist will be responsible for placing a date and time on all consents to verify that the patient was identified prior to the start of procedure.

Each anesthesia provider will confirm patient identification prior to administration of anesthesia in operating room by electronic signature on the anesthesia record of the electronic health care record system. Each surgeon will confirm patient identification prior to start of case by electronic signature on Intra op page 2 of the electronic health care record system.

All patient chart check forms will include a check of the date and time of informed consent, anesthesia electronic signature prior to administration of anesthesia, and surgeon electronic signature prior to start of case. The Administrator and Director of nursing will complete weekly audits verifying patient identification prior to surgery until 100% compliance is sustained consistently for a 3 month period starting on March 11, 2020.

Administrator will be responsible for reporting compliance to Quality Improvement & Performance Committee on a quarterly basis.

567.1 Principle LICENSURE CHAPTER 567 - ENVIRONMENTAL SERVICES:State only Deficiency.
567.1 Principle

The ASF shall have a sanitary environment, properly constructed,
equipped and maintained to protect surgical patients and ASF personnel from
cross-infection and to protect the health and safety of patients.

Observations:
Based on an observation tour, review of facility policy and interview with staff (EMP), it was determined the facility failed to provide a safe and sanitary environment for the provisions of surgical services.

Findings include:

An observation tour of the facility conducted on January 29, 2020, at 4:45 PM with EMP2 revealed the following:

1. Operating Room One contained a black surgical chair with a number of slits within the black leather like material with expose white cotton like substance.
2. Operating Room Two contained an intravenous pole with a brownish-red substance (rust) on the wheels and the each louver air vent contained a thick layer of a grayish color residue (dust).
3. Operating Room Three contained an intravenous pole with a brownish-red substance (rust) on the wheels and the each louver air vent contained a thick layer of a grayish colored residue (dust). Further observation revealed Wall hung hand sanitizer dispenser unit with hand sanitizer solution dated November 2019.
4. Anesthesia Workroom contained ceiling lights with dead bug matter visible through the ceiling mounted light covers.
5. Sterile Supply room four tier shelving unit did not contained a splatter guard on the lower shelf to protect items stored on the bottom shelf.

Review of facility policy "Patient Bill of Rights/Responsiblities" last dated July 12, 2018, revealed "...7. A patient has the right to good quality care and high professional standards that are continually maintained and reviewed."

An interview conducted January 29, 2020, at 5:05 PM with EMP2 confirmed Operating Room One had a black colored chair with exposed areas of a white cotton like substance protruding from the slits in the chair material. Operating Room (OR) Two and Operating Room Three had IV poles that contained rust on the wheels and air vents in the ORs with thick layers of dust. Continued interview with EMP2 confirmed dead insect matter visible within the covers of the ceiling lights in the Anesthesia Room and the 4-tier storage shelving unit in the sterile supply room did not contained a splash guard on the bottom shelf of the shelving unit to protect the integrity of sterile patient care supplies. In addition, EMP2 disposed of the outdated (November 2019) wall hung hand sanitizer solution in Operating Room 3. EMP2 further stated "I realize these issues are not in the best interest of the facility in maintaining compliance with the regulations for infection control."








 Plan of Correction - To be completed: 06/10/2020

Per policy IC 101: Responsibility of Infection Control, the director of nursing will be responsible for ensuring all equipment is maintained and a sanitary environment is provided for patients and staff.

Children's Dental Surgery of Malvern has removed all IV poles containing rust and replaced IV poles with new equipment in all OR's. An inventory of all chairs containing rips or slits has been conducted and new chairs have been ordered. A new environmental services team has been hired and oriented to the facility. A meeting between director of nursing, administrator, and cleaning crew took place to review importance of cleaning in all OR's including daily dusting. All hand sanitizer units have been inspected for outdated solution. All over head lighting has been inspected, any dust or bug matter present inside lights has been removed. New shelving liners have been ordered for all shelves in the Sterile supply closet.

Starting the week of 2/24/2020 an environmental checklist will be completed by the director of nursing to ensure 100% compliance with all aspects of this POC. The director of nursing will complete the environmental checklist weekly for 3 months, then monthly thereafter to ensure facility continues to have 100% compliance.

Each item contained within the environmental safety checklist will be verified via a weekly walk through and inspection of all items contained in the environmental checklist including upholstery on chairs, IV poles, lights inspected for dirt or debris and Operating Room vents inspected for dust.

The Director of Nursing will be responsible for this POC. The Administrator will be responsible for reporting compliance to the Infection Control Committee on a quarterly basis.


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