Pennsylvania Department of Health
SKIN CENTER, THE
Patient Care Inspection Results

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SKIN CENTER, THE
Inspection Results For:

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SKIN CENTER, THE - 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 December 4, 2023, at The Skin 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:


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 employee interview (EMP), it was determined that the applicants for medical staff membership failed to request specific clinical privileges in two of ten credential files reviewed (CF5 and CF10) and failed to grant specific clinical privileges in three of ten credential files reviewed (CF2, CF5, and CF10).

Findings include:


On December 4, 2023, a review of the Medical Staff Bylaws (Last Approved: May 18, 2023) revealed: "Article IV- Clinical Privileges; Section 4.2 Delineation of Privileges in General: 4.2-1: Requests- Each application for appointment and reappointment into the medical staff must contain a request for the specific clinical privileges desired by the applicant. A request by a member for the modification of clinical privileges may be made at any time, but such requests must be supported by documentation of training and/or experience. 4.2-2 Bases for Privilege Determination- Requests for clinical privileges shall be evaluated on the basis of the member ' s education, training, experience, demonstrated professional competence and judgement, clinical performance, and the documented results of patient care and other quality review and monitoring which the medical staff deems appropriate. Privilege determinations may also be based on pertinent information concerning clinical performance obtained from outside sources."


On December 4, 2023, a review of CF2 revealed that the applicant appropriately requested clinical privileges and was granted reappointment from May 9, 2022, to May 9, 2024. However, there was no indication in the file that the requested clinical privileges were granted by the governing body.


On December 4, 2023, a review of CF5 revealed that the applicant failed to request specific clinical privileges and the governing body failed to grant specific clinical privileges. However, the delineation of privilege form was signed and CF5 was granted appointment to the medical staff from January 23, 2023 through January 23, 2025.


On December 4, 2023, a review of CF10 revealed that the applicant failed to request specific clinical privileges and the governing body failed to grant specific clinical privileges. However, the delineation of privilege form was signed and CF10 was granted appointment to the medical staff from August 30, 2022 through August 30, 2024.


On December 4, 2023, at 12:21pm, EMP2 confirmed the above findings.








 Plan of Correction - To be completed: 04/15/2024

On December 5, 2023, the Center for Cosmetic Surgery, PC d/b/a The Skin Center reviewed procedures for the granting of clinical privileges and will follow the established policies and procedures currently set in the bylaws on requesting and granting clinical privileges for Physicians and CRNA's. The bylaws state that the written record of the application will include the scope of privileges sought and granted.

The three credentialing files that failed to request and/or granted specific clinical privileges were re-evaluated for appropriate privileges. The requested and/or granted clinical privileges were modified and approved. Privileges as requested and referenced were granted with the original credentialing period of two years. The Medical Director and Administrator approved and granted the updated privileges which were also approved by the Governing Body.

All thirteen Physicians and CRNA's credentialing files were reviewed on December 5th for the appropriate requested/granted privileges. There were no additional files with deficiencies. To ensure the policies of the bylaws are followed a log/report of all current and future Physician's and CRNA's will be implemented with a validation of the requested/granted clinical privileges by the Compliance Manager and Director of Nursing. The Medical Director and Administrator sign all medical staff privilege requested/granted forms. The log will be utilized for the next 3 months and will be completed on March 29, 2023. If after 3 months the audited files are 100% compliant (goal), the log can be discontinued, if not, the credentialing staff will be reeducated, and an additional 2 months will be added to achieve 100% compliance. The administrator will report the results of the credentialing report and any additional corrective action at the Quarterly Committee Meeting including the Governing Body scheduled for 4/15/2024.


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