Observations:
Based on review of facility documents, and interview with staff (EMP) it was determined the facility failed to notify the Department in writing at least 30 days prior to a change in ownership (CHOW).
Findings include:
Review on June 5, 2024, of an email correspondence from the facility to the Department, dated May 28, 2024, revealed "... Please accept this email as notification of change in ownership at Pottstown Ambulatory Center ... Pottstown USDH [aka Pottstown Ambulatory Surgery Center] had an ownership change January 1, 2023 ..."
Phone interview conducted on June 5, 2024, at approximately 1:45 PM with EMP1 confirmed a CHOW occurred on January 1, 2023, and confirmed a 30 day notification letter was not submitted to the Department.
| | Plan of Correction - To be completed: 07/15/2024
Pottstown Ambulatory Center will correct deficiency #0015 related to the ASF not providing at least 30-day prior notice of change of ownership to the Department of Health.
The ASF plans to conduct a board meeting with owners of the facility on 6/25/2024 reviewing policy #2019 "Change in Ownership, Organization, Operations, or Quality of Care Events". Education will be provided to owners on the policy and requirements. The board members will be required to sign off on the policy to ensure understanding of the regulation. The ASF administrator shall be responsible for ongoing monitoring and providing notification to the Department of Health for any change of ownership requirements. The ASF administrator shall require comment on any ownership changes, operation, or quality care events at each quarterly Quality meeting and report to board accordingly at the following board meetings to ensure appropriate notifications are provided to the Department of Health and CMS. This plan of correction shall be completed by 07/15/2024 after the next Quality meeting.
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