Initial Comments:
This report is the result of a full State Licensure survey completed on June 4, 2026, at Berks Ambulatory Surgery Center, LLC. 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:
553.25 (1-6) LICENSURE
Discharge Criteria
Name - Component - 00
553.25 Discharge Criteria
A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.
Observations:
Based on facility documents, medical record review (MR), and employee (EMP) interviews, it was determined the facility failed to ensure complete vital signs were obtained prior to discharge for three of ten medical records reviewed (MR1, MR2, and MR5).
Findings include:
Review of facility policy: "307: Discharge Criteria" with an effective date of March 31, 2022, revealed "Procedure: Assure that the patient has met the following criteria: Patient's vital signs are stable."
Review of MR1 on June 4, 2026, revealed no temperature and respiratory rate was taken prior to discharge.
Review of MR2 on June 4, 2026, revealed no temperature and respiratory rate was taken prior to discharge.
Review of MR5 on June 4, 2026, revealed no temperature and respiratory rate was taken prior to discharge.
Interview with EMP2 on June 4, 2026, at approximately 11:30 am, confirmed there were no temperatures or respiratory rates taken prior to discharge for three out of the ten medical records reviewed.
Plan of Correction:On order to comply with PA DOH Licensure Regulation 553.25, Section 1 pertaining to Discharge Criteria, the following changes have been completed on 6/5/2026:
1. Clinical Policy #409 – Care of the Patient Receiving Local Anesthesia, has been revised to include the following "Patients will be discharged following criteria set forth in Administrative Policy #370 – Discharge and Nursing Policy #307 – Discharge Criteria."
2. Local Assessment Paperwork has been revised to include temperature and respiration, with other vital signs for pre-operative and post-operative assessments.
Documentation of pre-operative and post-operative temperature and respiration, with other vital signs for patients receiving local anesthesia was implemented on June 5, 2026.
The pre-operative nurse is responsible for documenting vital signs before surgery and the peri-operative nurse is responsible for documenting vitals signs prior to patient discharge.
The Director of Nursing is responsible for reviewing all patient charts to verify compliance with this protocol.
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