Initial Comments:
This report is the result of a full Medicare recertification survey conducted on April 28, 2026, at New Britain Surgery Center, LLC. It was determined the facility was in compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions for Coverage for Ambulatory Surgical Centers.
Plan of Correction:
Initial Comments:
This report is the result of a full State Licensure survey conducted on April 28, 2026, at New Britain 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:
553.3(8)(v) LICENSURE
Governing Body Responsibilities
Name - Component - 00
553.3 Governing Body responsibilities include:
(8) Establishing personnel policies and practices which adequately support
sound patient care to include, the following:
(v) Written job descriptions shall exist for each type of job in the ASF.
Observations:
Based on review of personnel files (PF) and interview with staff (EMP), it was determined the facility failed to provide written job description in three of ten PF reviewed (PF1, PF5 and PF7).
Findings include:
Policy on the required contents of an Employee's Personnel File requested on April 28, 2026, to EMP1, none provided.
Review on April 28, 2026 of PF1 revealed no documentation written job description for the role of Director of Nursing.
Review on April 28, 2026 of PF5 revealed no documentation of a written job description for the role of Patient Safety Officer.
Review on April 28, 2026 of PF7 revealed no documentation of a written job description for the role of Infection Preventionist.
Interview on April 28, 2026 at 3:40 PM with EMP1 confirmed the above.
Plan of Correction:To comply with 28 Pa. Code Chapter 553.3, the Administrator created the following documents which were approved by the Board of Directors on May 6, 2026:
-Contents of Employee Personnel File
-Written Job Description for the role of Director of Nursing
-Written Job Description for the role of Infection Preventionist
-Written Job Description for the role of Patient Safety Office
The Administrator will be responsible for maintaining personnel files and ensuring job descriptions are current. Job descriptions will be reviewed at least annually and updated as needed with Board of Directors approval.
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