Initial Comments:
This report is the result of a full State Licensure survey initiated on April 08, 2026, and concluded on April 17, 2026, at Jefferson Surgical Center. It was determined the facility was 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:
553.21 (a) LICENSURE
Admission, Transfer & Discharge - Principle
Name - Component - 00
553.21 Principle
(a) Written policies for admission, discharge, transfer and proper referral of patients
Observations:
Based on review of facility policies and procedures and interview with staff (EMP) it was determined that the facility failed to ensure it had a written policy for the discharge of patients.
Findings include:
Request was made to EMP1 on April 08, 2026, for the facility's written policy for the discharge of patients. None provided.
Interview on April 08, 2026, with EMP1 confirmed the facility does not have a written policy for the discharge of patients.
Email from EMP1 dated April 09, 2026, 10:56, "... We do not have another policy that states patients can leave without an escort. There are discharge orders placed, but not that state without a ride... "
Plan of Correction:Upon notification of the deficiencies cited on April 22, 2026, a meeting was held to discuss the deficiencies and to formulate a full plan of correction. This meeting included the Director of Regulatory for TJUH, inc., the Director of Nursing for Jefferson Surgical Center (JSC), the Director of Risk Management for TJUH, inc., the Vice President of Perioperative Operations / Administrator for JSC, the Chief Clinical Officer of TJUH, inc., and the Vice President and Chief Nursing Officer for TJUH, inc. In addition, the JSC Quality Committee met and reviewed the deficiencies cited and plan of correction.
In response to these deficiencies, Jefferson Surgical Center will create a new Discharge Policy that includes the discharge criteria for patients and will outline the discharge process. As part of this Discharge Policy, a Discharge Acknowledgment form has been created and will be implemented, pending approval at the Medical Records Committee meeting on 5/11/26, for all patients undergoing anesthesia to inform them of the requirement to have a responsible person present in order to be discharged from the facility. The Discharge Policy will include the process for patients that meet the discharge criteria but do not have a responsible person present. Any patient that does not have a responsible person present will be transferred to Thomas Jefferson University Hospital (TJUH). If the patient refuses to be transferred to TJUH, the patient will have an Against Medical Advice discharge order placed by a provider into the electronic medical record system, and the patient will be considered as leaving Against Medical Advice from the facility. For any patient that does not have a responsible person present for discharge, an incident report will be documented via the electronic reporting system.
All JSC Nursing staff will be educated on the new Discharge Policy, including the full process for any patient that does not have a responsible person present for discharge. This education will include the requirement of the Discharge Acknowledgement form. In addition, the JSC Medical Director and designated anesthesia providers will be educated on the Discharge Policy and process, including the requirement of a discharge order that states the patient is leaving against medical advice.
To ensure project monitoring and tracking, the JSC leadership team (the Director of Nursing, Medical Director, and Patient Safety Officer) will audit all medical records of patients without a responsible person present for discharge to ensure compliance with the process outlined in the Discharge Policy, including having the appropriate discharge order. Audits will continue until 100% compliance is met and maintained for 3 consecutive months, and then quarterly for the remainder of the year. Audits completed for June, July and August will be reported to the JSC Quality Committee monthly and then quarterly for the remainder of the year and will also be reported the TJUH Inc. Board of Trustees Committee, quarterly for one year.
555.24 (e) LICENSURE
Surgical Services - Postoperative Care
Name - Component - 00
555.24 Postoperative Care
(e) Patients shall be discharged in the company of a responsible person, if one is deemed to be necessary under 555.22 (c)(5) (relating to preoperative care).
Observations:
Based on review of facility documents, medical records (MR) and interview staff (EMP) it was determined the facility failed to ensure patients were safely discharged with a responsible party for six of six discharge records reviewed. (MR1, MR2, MR3, MR4, MR5, MR6)
Findings include:
Review on April 08, 2026, of facility policy "Moderate Sedation (Conscious Sedation), 113.06, "... Patients who receive moderate sedation, other than local on an ambulatory basis shall be accompanied by a designated person (adult, emancipated minor, parent) who will assume responsibility for the patient at discharge. A taxi driver or (courtesy) driver does not qualify as a designated or responsible person ... "
Review on April 08, 2026, of MR1, MR2, MR3, MR4, MR5, MR6, revealed these patients presented to the surgery center between the dates of January 14, 2026, and March 23, 2026, for procedures requiring the use of anesthesia sedation other than local anesthesia.
Interview on April 08, 2026, with EMP1 confirmed the patients in the above MR's were discharged without a responsible person.
Plan of Correction:Upon notification of the deficiencies cited on April 22, 2026, a meeting was held to discuss the deficiencies and to formulate a full plan of correction. This meeting included the Director of Regulatory for TJUH, inc., the Director of Nursing for Jefferson Surgical Center (JSC), the Director of Risk Management for TJUH, inc., the Vice President of Perioperative Operations / Administrator for JSC, the Chief Clinical Officer of TJUH, inc., and the Vice President and Chief Nursing Officer for TJUH, inc. In addition, the JSC Quality Committee met and reviewed the deficiencies cited and plan of correction.
In response to these deficiencies, Jefferson Surgical Center will create a new Discharge Policy that includes the discharge criteria for patients and will outline the discharge process. As part of this Discharge Policy, a Discharge Acknowledgment form has been created and will be implemented, pending approval at the Medical Records Committee meeting on 5/11/26, for all patients undergoing anesthesia to inform them of the requirement to have a responsible person present in order to be discharged from the facility. The Discharge Policy will include the process for patients that meet the discharge criteria but do not have a responsible person present. Any patient that does not have a responsible person present will be transferred to Thomas Jefferson University Hospital (TJUH). If the patient refuses to be transferred to TJUH, the patient will have an Against Medical Advice discharge order placed by a provider into the electronic medical record system, and the patient will be considered as leaving Against Medical Advice from the facility. For any patient that does not have a responsible person present for discharge, an incident report will be documented via the electronic reporting system.
All JSC Nursing staff will be educated on the new Discharge Policy, including the full process for any patient that does not have a responsible person present for discharge. This education will include the requirement of the Discharge Acknowledgement form. In addition, the JSC Medical Director and designated anesthesia providers will be educated on the Discharge Policy and process, including the requirement of a discharge order that states the patient is leaving against medical advice.
To ensure project monitoring and tracking, the JSC leadership team (the Director of Nursing, Medical Director, and Patient Safety Officer) will audit all medical records of patients without a responsible person present for discharge to ensure compliance with the process outlined in the Discharge Policy, including having the appropriate discharge order. Audits will continue until 100% compliance is met and maintained for 3 consecutive months, and then quarterly for the remainder of the year. Audits completed for June, July and August will be reported to the JSC Quality Committee monthly and then quarterly for the remainder of the year and will also be reported the TJUH Inc. Board of Trustees Committee, quarterly for one year.
555.24 (g) LICENSURE
Surgical Services - Postoperative
Name - Component - 00
555.24 Post Operative Care
(g) Patients shall be discharged only upon the written signed order of a practitioner.
Observations:
Based on review of medical records (MR) and interview staff (EMP) it was determined the facility failed to obtain a written discharge order for six of six medical records reviewed. (MR1, MR2, MR3, MR4, MR5, MR6)
Findings include:
Review on April 08, 2026, MR1, MR2, MR3, MR4, MR5, MR6, revealed no discharge orders were written prior to the patient leaving the facility.
Interview on April 08, 2026, with EMP1 confirmed the patients in the above MR's did not have written discharge orders.
Plan of Correction:Upon notification of the deficiencies cited on April 22, 2026, a meeting was held to discuss the deficiencies and to formulate a full plan of correction. This meeting included the Director of Regulatory for TJUH, inc., the Director of Nursing for Jefferson Surgical Center (JSC), the Director of Risk Management for TJUH, inc., the Vice President of Perioperative Operations / Administrator for JSC, the Chief Clinical Officer of TJUH, inc., and the Vice President and Chief Nursing Officer for TJUH, inc. In addition, the JSC Quality Committee met and reviewed the deficiencies cited and plan of correction.
In response to these deficiencies, Jefferson Surgical Center will create a new Discharge Policy that includes the discharge criteria for patients and will outline the discharge process. As part of this Discharge Policy, a Discharge Acknowledgment form has been created and will be implemented, pending approval at the Medical Records Committee meeting on 5/11/26, for all patients undergoing anesthesia to inform them of the requirement to have a responsible person present in order to be discharged from the facility. The Discharge Policy will include the process for patients that meet the discharge criteria but do not have a responsible person present. Any patient that does not have a responsible person present will be transferred to Thomas Jefferson University Hospital (TJUH). If the patient refuses to be transferred to TJUH, the patient will have an Against Medical Advice discharge order placed by a provider into the electronic medical record system, and the patient will be considered as leaving Against Medical Advice from the facility. For any patient that does not have a responsible person present for discharge, an incident report will be documented via the electronic reporting system.
All JSC Nursing staff will be educated on the new Discharge Policy, including the full process for any patient that does not have a responsible person present for discharge. This education will include the requirement of the Discharge Acknowledgement form. In addition, the JSC Medical Director and designated anesthesia providers will be educated on the Discharge Policy and process, including the requirement of a discharge order that states the patient is leaving against medical advice.
To ensure project monitoring and tracking, the JSC leadership team (the Director of Nursing, Medical Director, and Patient Safety Officer) will audit all medical records of patients without a responsible person present for discharge to ensure compliance with the process outlined in the Discharge Policy, including having the appropriate discharge order. Audits will continue until 100% compliance is met and maintained for 3 consecutive months, and then quarterly for the remainder of the year. Audits completed for June, July and August will be reported to the JSC Quality Committee monthly and then quarterly for the remainder of the year and will also be reported the TJUH Inc. Board of Trustees Committee, quarterly for one year.
557.3 (e) LICENSURE
QA & Improvement Program
Name - Component - 00
557.3 The Quality Assurance and Improvement Program
(e) The program shall include a mechanism to assure that activities are documented and reports of the quality assurance activities are brought to the attention of the governing body. There shall be a
periodic reappraisal of the program.
Observations:
Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to ensure that the results of the facility's Quality Insurance Program was formally reviewed by the Governing Body.
Findings include:
Review on April 08,2026 of facility document "Quality Improvement in the Jefferson Surgical Center" revised March 2025, revealed "... Committee minutes are documented and reported to the governing body ..."
Review on April 08, 2026, of the Governing Body meeting minutes dated, November 12, 2025, revealed no documentation of the activities of the Quality Assessment and Improvement Program and that reports of the program's activities are brought to the attention of the Governing Body.
In an email dated April 09, 2026, from EMP1 to this surveyor confirmed "no it did not go to the board."
Plan of Correction:Upon notification of the deficiencies cited on April 22, 2026, a meeting was held to discuss the deficiencies and to formulate a full plan of correction. This meeting included the Director of Regulatory for TJUH, inc., the Director of Nursing for Jefferson Surgical Center (JSC), the Director of Risk Management for TJUH, inc., the Vice President of Perioperative Operations / Administrator for JSC, the Chief Clinical Officer of TJUH, inc., and the Vice President and Chief Nursing Officer for TJUH, inc. The JSC policy titled ""Quality Improvement in the Jefferson Surgical Center Policy", was reviewed and compliance was reinforced at this meeting. This was also discussed with the JSC Medical Director. In addition, the JSC Quality Committee met and reviewed the deficiencies cited and plan of correction.
In response to this deficiency, Jefferson Surgical Center will ensure that the JSC Quality Committee minutes are reported to the TJUH, Inc. Board of Trustees (BOT) Committee meeting, held quarterly. The need for compliance with this policy will also be reported at the TJUH, Inc. Patient Safety and Medical Executive Committees.
All members of the JSC Quality Committee, will be educated on the current version of the JSC policy titled "Quality Improvement in the Jefferson Surgical Center Policy". This education will include the requirement of the current version of the policy which states in part that "[Quality] Committee minutes are documented and reported to the governing body."
To ensure project monitoring and tracking, the JSC Director of Nursing will add a standing agenda item to the JSC Quality Committee meetings and will confirm submission of the JSC Quality Committee meeting minutes to the TJUH, Inc. BOT at the Quality Committee meeting each quarter.
|