Initial Comments:
This report is the result of an unannounced revisit survey conducted on December 20, 2023, as a result of a previous unannounced revisit survey conducted on August 16, 2023, which was a result of a State Licensure survey completed on May 25, 2023, at Surgery Center of Bucks County. 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:
551.101 LICENSURE
Correction of Deficiency - Policy
Name - Component - 00
551.101 Policy
If an ASF notifies the Department that it has completed a plan of correction and corrected its
deficiencies, the Department will conduct a survey to ascertain completion of the plan of correction.
Upon finding full or substantial compliance, as defined in 551.82 (b)(relating to a regular license),
the Department will issue a regular license.
Observations:
Based on review of the facility's Plan of Correction (PoC), medical records (MR), facility policy and procedure and interview with staff (EMP), it was determined the facility failed to correct deficient practice by failing to follow the Plan of Correction submitted and accepted by the Department for the survey dated August 16, 2023. The corrective action date as approved by the Department was September 6, 2023
Findings include:
Review on August 15, 2023, of the facility's PoC statement for 555.11 Medical Orders, revealed "Corrective Action: Facility policy 'Medical Orders' All physicians and nursing staff will be re-educated on the revised standing order physician treatment/order sheets ... Each physician will identify the medication therapy on the standing order for the patient ... "
Review on December 20, 2023, of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9 and MR10 revealed the application of the "Standing Orders" did not follow establish policy for each physician to identify medication therapy on the standing order.
Interview on December 20, 2023, at 12:30 PM with EMP2 confirmed the facility did not comply with their plan of correction that was submitted to the Department and approved September 6, 2023.
Plan of Correction:All physicians and nursing staff will be re-educated on the revised medication orders indicating the patient will be assessed for appropriateness of implementing the medical order by the surgeon in the preoperative area on the day of surgery.
In addition to the preoperative medication orders, unless otherwise indicated, the surgeon may write additional orders related to health changes and/or allergies. Substitutions for these medications may also be ordered.
The Administrator, Director of Nursing and Infection Control Nurse will audit 10 patient charts daily for 2 weeks to ensure compliance. Results of the audits will be reported to the Safety Committee as well as the Medical Advisory and Governing Boards.
Ongoing performance will be monitored by including a medication order to the monthly chart audit. Fifteen charts are audited monthly. Identified non-compliance will be reported to the Medical Director for discussion with the provider.
Results will be reported by the Administrator to the Patient Safety and Quality Improvement, Risk Management, Medical Advisory and Governing Board committees. The Medical Director and Administrator are responsible for this plan of correction and will be presented to the Medical Advisory and Governing Boards.
555.11 (a) LICENSURE
MEDICAL ORDERS - Written
Name - Component - 00
555.11 Medical orders
Written orders
(a) Medication or treatment shall be administered by authorized persons to administer drugs and medications only upon written and signed orders of a practitioner acting within the scope
of the practitioner's license.
Observations:
Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to follow established policy to follow a standardized format for the implementation and completion of standing orders.
Findings include:
Review on December 20, 2023, 2023, of facility policy "Standing Orders" revised August 16, 2023, revealed "... Standing Orders must ... follow a standardized format for the prescriber to select desired orders [checkbox or circle] ..."
Review on December 20, 2023, of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9 and MR10 revealed these patients presented to the surgery center for a surgical procedure between the dates of October 5, 2023 thru November November 29, 2023. Further review of physician documentation "Standing Physician Treatment/Order Sheet" revealed no documentation for a standardized format to select orders, via checkbox or circle, that were specific to the patient's needs and condition.
Interview on December 20, 2023, with EMP2 confirmed the standing order document did not follow the facility's established policy for a standardized format to select orders via checkbox or circle that were specific to the patient's needs and condition.
Plan of Correction:All physicians and nursing staff will be re-educated on the revised medication order physician treatment order sheet. The patient will be assessed for appropriateness of implementing the medication order by the surgeon in the preoperative area on the day of surgery. The revised medication orders do not include the need for circles or check boxes.
The Administrator, Director of Nursing and Infection Control Nurse will audit 10 patient charts daily for 2 weeks to ensure compliance. Results of the audits will be reported to the Safety Committee as well as the Medical Advisory and Governing Boards.
Ongoing performance will be monitored by including a medication order to the monthly chart audit. Fifteen charts are audited monthly. Identified non-compliance will be reported to the Medical Director for discussion with the provider.
Results will be reported by the Administrator to the Patient Safety and Quality Improvement, Risk Management, Medical Advisory and Governing Board committees. The Medical Director and Administrator are responsible for this plan of correction and will be presented to the Medical Advisory and Governing Boards.
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