Observations:
Based on a review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to ensure the required committee members of the Quality Improvement Committee were in attendance as representatives of the ambulatory surgical center (ASC) during the Quality Improvement Committee meetings.
Findings include:
Review of facility policy "Quality Improvement in the Jefferson Surgical Center " last revised January 2023 revealed "The Quality Improvement Committee consists of the following members: a practitioner who is not an owner, a representative of administration, a registered nurse and other health care personnel, as appropriate.
Review of facility document "Jefferson Surgical Center Quality Meeting minutes" dated July 25, 2023, revealed a practitioner who is not an owner was not present at the quality meeting.
Review of facility document "Jefferson Surgical Center Quality Meeting minutes" dated November 28, 2023, revealed a practioner who is not an owner, and a representative of administration was not present at the quality meeting.
Review of facility document "Jefferson Surgical Center Quality Meeting minutes" dated January 23, 2024, revealed a practitioner who is not an owner was not present at the quality meeting.
Review of facility document " Jefferson Surgical Center Quality Meeting minutes" dated March 26, 2024, revealed a representative of administration was not present at the quality meeting.
An interview conducted on May 7, 2024, at 2:37 PM with EMP3 confirmed the above findings.
| | Plan of Correction - To be completed: 07/31/2024
-The Director of Nursing, the Administrator and Medical Director of the Jefferson Surgical Center met with the Chair of the Department of Anesthesiology and Perioperative Medicine to discuss solutions around this citation. The solution was that all required members of the Jefferson Surgical Center Quality Committee will be present at the monthly meetings. If a required member is unable to join the meeting for any reason, an appropriate designee must be assigned in their absence, or the meeting will be re-scheduled.
- The Jefferson Surgical Center Quality Committee members will be notified of this finding at the next meeting on 7/23/24. All committee members will be informed of the action plan and will be required to verify their understanding that they must be present for every meeting. If a committee member cannot make the monthly meeting, they will be responsible to designate an appropriate team member in their place. Written confirmation from every committee member will be obtained by 7/31/24.
-The Jefferson Surgical Center Quality Committee members will be notified of this finding and the corrective action plan at the next meeting on 7/23/24. The committee member responsible for recording meeting minutes will verify that all required members are present before Proceeding with the meeting as scheduled. If a quorum is not present, the meeting will be re-scheduled. If required participants are unavailable, the Administrator or Director of Nursing will follow-up via email to ensure there is a designee prior to the meeting Minutes are sent to the committee and approved at each meeting. If committee members fail to comply with membership requirements, including participation in committee meetings, their position will be replaced.
-At the start of the meeting, The Jefferson Surgical Center Director of Nursing will review the attendance to ensure all required members are present and document the attendance at every Jefferson Surgical Center Quality Committee meeting starting on 7/23/24 and every meeting thereafter, to ensure 100% compliance is achieved. Any deficiency will be reported to the Jefferson Surgical Center Director of Nursing, Administrator, and Medical Director, and the regulatory office. The Jefferson Surgical Center Director of Nursing, Administrator and the Medical Director are responsible for the implementation and execution of the plan.
-The Jefferson Surgical Center Director of Nursing, Administrator and the Medical Director are responsible for this corrective action plan. Plan will be complete by 7/23 /24. Attendance will be reviewed beginning on 7/23/24 and will continue every meeting to ensure 100% compliance is achieved and maintained. Progress towards this goal will be monitored and reported monthly to the Jefferson Surgical Center Quality committee and quarterly to the governing body.
|
