QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
Health Inspection Results For:

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Initial Comments:
This report is the result of a State licensure survey conducted on September 21, 2022, at Crozer-Keystone Center At Haverford. 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:

Medical staff membership

Name - Component - 00
555.2 Medical Staff Membership

A member of the medical staff shall be qualified for membership and the exercise of clinical privileges granted to him. The governing body of the ASF, after considering the recommendations of the medical staff, may grant clinical privileges to qualified, licensed practitioners in accordance with their training, experience and demonstrated competence and judgement. Members of the medicals staff and others granted clinical privileges shall currently hold licenses to practice in this Commonwealth.


Based on review of facility documents, credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure that there was documentation by the Medical Staff and Governing Body of current delineation of privileges for five of ten credentialing files (CF) reviewed CF1, CF3, CF6, CF7, CF8. No documentation for DEA license in CF3 and no insurance liability in CF6.

Findings include:

A review of facilities MEDICAL Staff BYLAWS Of Delaware County Memorial Hospital
" ...3.2 BASIC QUALIFICATIONS/CONDITIONS OF STAFF MEMBERSHIP (a) Basic Qualification Only Practitioners who continuously satisfy the following conditions shall be qualified for appointment and/or reappointment to the Medical Staff: ... Possess evidence of current, valid professional liability insurance coverage in form and amounts that meets the requirements of the laws of the Commonwealth of Pennsylvania; (6) Possess a current, valid Drug Enforcement Agency (DEA) registration (if applicable); ...4.3 Active Ambulatory Staff (a) Qualifications. The Active Ambulatory Staff shall consist of Practitioners who meet the basic qualifications in the Bylaws (See Section 3.2) ... 7.2 DELINEATION OF PRIVILEGES IN GENERAL (b) Basis for privileges Determination ... The grant of Clinical Privileges shall be based upon the availability of facilities, equipment and number of qualified support personnel and resources as well as on the Practitioner's or APC's education, training, current competence, including documented experience, treatment areas or procedures, the results of treatment, and the conclusions drawn from performance improvement activities, when available. ... In addition, those Practitioners or APC's seeking new, additional or renewed Clinical Privileges must meet all criteria for Medical Staff membership as described in Article VI of these Bylaws ... Clinical privileges granted or modified on pertinent information concerning clinical performance obtained from other health care institutions or practice settings shall be added to and maintained in the Medical Staff credentials file established for the Practitioner or APC ... "

Review of CF1, CF3, CF6, CF7, and CF8 revealed no documentation of current delineation of privileges.

Review of CF3 revealed no documentation for a DEA license.

Review of CF6 revealed no documentation for insurance liability.

Interview with EMP1 on September 21, 2022, at 3:00 PM confirmed there were no delineation of privileges, DEA license and insurance liability in the credentialing files.

Plan of Correction:

A meeting was held on 10/19/2022 to review procedures related to provider credentialing. Members of the team included the Chief Medical Officer, Chief Nursing Officer, Hospital Administrator, Surgery Center Administrator, Director of Medical Staff Affairs, and Director of Regulatory Affairs. Based on this interview, the team has developed the following plan of correction.

100% of available Medical Affairs staff will be reeducated on the Rules & Regulations and Bylaws of the Medical Staff by Friday 11/4/2022.

The Director of Medical Staff Affairs or a designee will complete a full audit of all provider files at Haverford Surgery Center by 12/9/2022. 100% of new appointments and re-appointments will be audited on a monthly bases. All audit data will be reported monthly to the Quality of Care Committee by hospital leadership for 3 months. The status of provider files at Haverford will be reported monthly to the Medical Executive Committee by the Director of Medical Staff Affairs or a designee until the full provider audit is complete.

The Chief Medical Officer is ultimately responsible for this plan of correction.