Pennsylvania Department of Health
WILLS EYE SURGERY CENTER OF THE NORTHEAST
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WILLS EYE SURGERY CENTER OF THE NORTHEAST - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a State Relicensure survey conducted on July 26, 2023, at Wills Eye Surgery Center of the Northeast. 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:

553.3 (1) LICENSURE Governing Body Responsibilities:

553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.

Observations:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to applicable State laws.

Wills Eye Surgery Center of the Northeast was not in compliance with the following state law:

"Act 13 of 2002
MEDICAL CARE AVAILABILITY AND REDUCTION OF ERROR (MCARE) ACT
Section 310. Patient safety committee.

(b) Responsibilities.--A patient safety committee of a medical facility shall do all of the following:
(1) Receive reports from the patient safety officer pursuant to section 309.
(2) Evaluate investigations and actions of the patient safety officer on all reports.
(3) Review and evaluate the quality of patient safety measures utilized by the medical facility. A review shall include the consideration of reports made under sections
304(a)(5) and (b), 307(b)(3) and 308(a).
(4) Make recommendations to eliminate future serious events and incidents.
(5) Report to the administrative officer and governing body of the medical facility on a quarterly basis regarding the number of serious events and incidents and its recommendations to eliminate future serious events and incidents.

This is not met as evidenced by:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to have a stand-alone Patient Safety Committee.

Findings include:
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to establish a stand-alone Patient Safety Committee, as required by The Medical Care Availability and Reduction of Error Act of 2002 (MCARE).
Findings include:
Review on July 26, 2023, of "Wills Surgery Center - Northeast Administrator's Report," dated September 13, 2022, December 13, 2022, March 14, 2023, and June 13, 2023, revealed the Patient Safety Meetings were combined with the Quality committee meeting minutes.

Interview on July 26, 2023, at 2:15 PM, with EMP1 confirmed the Patient Safety Committee was not a stand-alone committee and was combined with the Quality committee.

Plan of Correction - To be completed: 10/20/2023

The facility will hold a stand-alone Patient Safety Committee meeting that meets The Medical Care Availability and reduction of Error Act of 2002. The quarterly meeting will not be combined with the Quality Improvement Committee meeting minutes or any other meeting.
The Director of Nursing will conduct a quarterly audit of the Patient Safety Committee meeting to ensure the committee:
1. Receives reports from the patient Safety officer.
2. Evaluates investigations and actions of the patient safety officer on all reports.
3. Review and evaluate the quality of patient safety measures utilized by the facility.
4. The facility will have a stand-alone Patient Safety Commitee.
The Administrator will be responsible to monitor the continued implementation of the plan of correction. Identified non-compliance will be addressed by the Administrator at the time of combined meeting minutes. Results will be reported by Administrator to the Patient Safety Committee, the Quality Improvement Committee, Risk Management, Medical Advisory Board and Governing Body Committees.

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