Pennsylvania Department of Health
MUVE - WEST CHESTER AMBULATORY SURGICAL CENTER, LLC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 14 surveys for this facility. Please select a date to view the survey results.

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MUVE - WEST CHESTER AMBULATORY SURGICAL CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced revisit survey conducted on April 3, 2024, following a State Licensure survey completed on February 8, 2024, at MUVE - West Chester Ambulatory Surgical Center, LLC. It was determined that 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:

551.64 LICENSURE Content of plan of correction:

551.64 Content of Plan of Correction

A plan of correction shall address deficiencies cited in the compliance directive of the Department. the plan shall state specifically what corrective action is to be taken, by whom and when.

Observations:

Based on review of facility's Plan of Correction (PoC), documents provided by the facility, and staff interview (EMP), it was determined the facility failed to implement the approved plan of correction and correct the deficient practice regarding peer review.

Findings include:
A review of the facility's PoC, revealed, " ...The center reviewed all APP [advanced practice practitioners] charts and had a peer review done for providers who did not receive a peer review at the time of their recredentialing ... Completion date 2/19/24 ..."

On April 3, 2024, documentation of the peer review was asked to be provided. No documentation was available.

Interview with EMP1 confirmed peer reviews were not completed according the PoC submitted.

Cross reference with 555.3 (b) Requirements for membership and privileges.

Plan of Correction - To be completed: 04/28/2024

Peer review forms for APP's obtained from Surgery Partners. Forms were scheduled to be presented at the MEC meeting on 4/4/2024 then to Governing Board on 4/18/2024. Due to 2 of the MEC members having unexpected emergent cases, MEC was postponed until 4/18/2024. MEC to meet prior to the Board Meeting on 4/18/24. Forms will be presented to the MEC and the Board on 4/18/2024. Once approved, peer evaluations will be completed within 10 business days.

555.3 (b) LICENSURE Requirements:

Privileges granted shall reflect the results of peer review or utilization review programs, or both, specific to ambulatory surgery.

Observations:

Based on review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure a peer review was performed on four of ten credential files reviewed (CF2, CF3, CF5, CF10).

Findings include:

Review on February 8, 2024, of the facility's "Peer Review" policy revealed, "The Muve West Chester Ambulatory Surgical Center will conduct Peer Review will be on all medical staff members and the Allied Health Staff on a continuous basis. The purpose of the medical staff peer review plan is to document the process at the Surgery Center for implementing and conducting a physician and allied health, peer review monitoring and evaluation process. All clarifications of this plan will follow the Bylaws of the Medical Staff. All physicians and allied health practitioners, privileged by the organization, will be subject to peer review as outlined in this plan ..."

Review of CF2 revealed no peer review documentation.

Review of CF3 revealed no peer review documentation.

Review of CF5 revealed no peer review documentation.

Review of CF10 revealed no peer review documentation.

Interview with EMP1 on April 3, 2024, at approximately 12:00 PM confirmed the facility did not have documentation for peer reviews on CF2, CF3, CF5, and CF10.

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