This report is the result of an Annual Registration survey conducted on May 4, 2021, at PPSP West Chester Health Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.
Plan of Correction:
Requirements for Abortion
Name - Component - 00
Abortions shall be performed only by a physician who possesses the requisite professional skill and competence as determined and approved by the medical facility in accordance with appropriate procedures.
Based on a review of facility documents and interview with staff (EMP) it was determined that the facility failed to have updated Certification of Clinical Privileges forms for two of five physicians' credentialing files (CF) reviewed.
Review of policy: " Abortion Provider Privileging and Medical Staff Appointment Revised April 24, 2021 ... Requirements for Membership and Privileges: ... Granting of clinical privileges shall follow established policies and procedures in the bylaws or similar rules and regulations. The procedures shall provide the following: A written record of the application, which includes the scope of privileges sought and granted. The delineation of " clinical privileges " shall address the administration of anesthesia. ... Medical Staff Appointment and Clinical Privileges: For initial appointments and biennial re-appointment, the provider must complete the following at least one (1) month prior to the Board ' s scheduled review: 1. Complete Certification of Clinical Privileges (initial) and / or Annual Competency Review (re-appointment) for the provision of abortion care and must include delineation of privileges (e.g. Medication Abortion, Surgical Abortion, Ultrasound, Local Paracervical Block/local anesthesia, Molar Pregnancy Management, Ectopic Pregnancy Management, Early Pregnancy Loss Management) approved by PPSP Medical Director; .... Following Board approval, the HR Director will inform the provider by letter; also, the HR Director will file the following documents in the provider ' s credential file: Certification of Clinical Privileges, Application for Clinical Privileges/ Medical Staff Appointment, Documentation of Board consideration (agenda) and approval( minutes)
CF 1 did not have a current Certification of Clinical Privileges form from the December 2020 reappointment.
CF 4 did not have a current Certification of Clinical Privileges form from the December 2020 reappointment.
Interview with employee (EMP) 1 confirmed there was not an updated privileging form in CF 1 and CF 4.
Plan of Correction:
As of 6/1/2021, all provider credential files have been updated to include evidence of clinician privileges from December 2020 re-appointment in alignment with PPSP's Abortion Provider Privileging and Medical Staff Appointment Policy (last revised April 24, 2021). Privileges were granted by the Medical Director and/or Medical Director Designee based on Annual Peer Review. Updated credential files are immediately available for Department review.
At the next CRQM (Compliance, Risk, Quality and Management) Committee Meeting (week of June 21st), the Director of Patient Services and Director of Human Resources will review the Abortion Provider Privileging and Medical Staff Appointment policy and process. As per the policy, all appointment and reappointment applications and privileging documents are submitted to the Board of Directors (Governing Body) for review and approval (next meeting scheduled for June 24). In addition, the Human Resources Director conducts periodic (quarterly) review of credential files to ensure compliance with established policy and they ensure Center Manager has access to the most current documentation. The Director of Patient Services is responsible for completion of this Plan of Correction and compliance to written policy and procedure.