Observations:
Based on a review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure the Department was notified within 30 days after a change in management.
Findings include:
A review on April 18, 2024, of facility documentation, Responsibility of Medical Director revealed " ... 1.3. Must be available to provide consultation to the Center or medical staff in the area of services performed in the Center. 2. DUTIES AND RESPONSIBILITIES: ... Provides consultation in the ambulatory care service area as requested by medical or Center staff ... Abide by and enforce the medical staff bylaws and related medical staff policies and procedures and clinical protocols at all times. Counsel non-compliant members of the medical staff on adherence to such policies, procedures and protocols. ... Participate actively in quality management and review, utilization review, utilization review, risk management, infection control, and other medical programs at Center. ... Be available for consultation related to day-to-day medical operations and issues and patient care problems. ... "
1. Review of the facility application request form at approximately 1:35 PM on April 18, 2024, revealed the Medical Director is EMP3. Review of the previous application request form revealed EMP3 is not listed on the form as the Medical Director. No notification was provided to the Department related to the change in management.
EMP2 confirmed the findings via email communication on April 18, 2024, and indicated EMP3 is the Medical Director effective January 1, 2024.
| | Plan of Correction - To be completed: 04/24/2024
Plan of correction:
*What corrective action will be accomplished for those residents/patients found to have been affected by the deficient practice?
The center manager will give proper notification of 30 days to the PA DOH notifying of any and all new changes in management including the medical director at Pittsburgh North Surgical Center.
*How you will identify other residents/patients having the potential to be affected by the same deficient practice and what corrective action will be taken.
With proper notification and clearance given of management changes, there is no anticipation of any patients being affected by this deficiency.
*What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur?
The proper notification will be submitted with 30 days' notice and this will be verified by the corporate clinical director.
*How the corrective action will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place?
Verification of notification submission is to be checked by the corporate clinical director in conjunction with the center manager to ensure any changes in management including medical are first submitted to the DOH and acknowledgment of this change is received. Monitoring will be checked and addressed during the quarterly governing body meetings to discuss if any changes in management have occurred and if PA DOH has been notified.
*The plan must include the title of the person responsible for implementing the acceptable plan of correction.
Center Manager and Senior Director, Clinical Operations
*Include date(s) when the corrective action(s) will be completed. The corrective action completion date(s) must be acceptable and should not exceed 60 days past exit date of survey. (audits are excluded in this timeframe as it is expected that they will continue beyond 60 days to ensure compliance with PoC).
On 4/19/24 we received deficiency for untimely notification of a change in medical director. On 4/24/24 the DAAC has been notified and deficiency has been corrected.
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