Initial Comments:
This report is the result of a full State Licensure survey conducted on October 27, 2023, at UPMC Hamot Surgery Center, LLC, with additional documentation review concluding on October 30, 2023. 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 (1) LICENSURE
Governing Body Responsibilities
Name - Component - 00
553.3
Governing Body responsibilities include:
(1) Conforming to all applicable Federal, State, and local laws.
Observations:
Based on review of facility documentation and employee interview (EMP), it was determined that the facility failed to conform to all applicable State Laws.
The facility was found to be non-compliant with the following State Law:
UPMC Hamot Surgery Center, Llc was not in compliance with Act 52 of 2007 Medical Care Availability and Reduction of Error (MCARE) Act - Reduction and Prevention of Health Care Associated Infection and Long-Term Care Nursing Facilities, Act 52 of 2007.
(a) Development and compliance, -- Within 120 days of the effective date of this sections, a health care facility, and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following if applicable to that specific health facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor
(v) Pharmacy staff that could include the chief of pharmacy
(vi) Physical plant personnel
(vii) A patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.
This is not met as evidence by:
Based on review of facility documentation and employee interviews (EMP), it was determined that the facility failed to ensure that a multidisciplinary committee included members of medical staff and community representation.
Findings include:
Review, at approximately 1:25 PM on October 29, 2023, of "Title: Infection Control Plan," dated September 19, 2023, revealed, "... D. The Infection Control Committee: ... a. The Infection Control Committee reports to the Quality Assurance and Performance Improvement (QAPI) Committee: 1. The Infection Control Committee consists of: iv. Medical Director/Anesthesia Services; ..." Further review revealed the policy did not include the requirement for The Infection Control Policy to include Community Members.
1. Review, at approximately 10:30 AM on October 27, 2023, of "UPMC Hamot Surgery Center Infection Control Committee Meeting," dated April 12, 2023, revealed that the multidisciplinary committee did not include members of medical staff and community representation.
2. Review, at approximately 10:31 AM on October 27, 2023, of "UPMC Hamot Surgery Center Infection Control Committee Meeting," dated July 19, 2023, revealed that the multidisciplinary committee did not include members of medical staff and community representation.
3. Review, at approximately 10:33 AM on October 27, 2023, of "UPMC Hamot Surgery Center Infection Control Committee Meeting," dated January 18, 2023, revealed that the multidisciplinary committee did not include members of medical staff and community representation.
At approximately 10:40 AM on October 27, 2023, EMP1 confirmed the above findings.
Plan of Correction:In response to the citation.
The infection control committee will be held quarterly and immediately following the quarterly patient safety meeting.
The Infection Control committee has identified a community member willing to actively participate.
The membership includes RNs and Techs from both OR and GI units, OR and GI Nurse Managers, community member, Medical Director, Director of Nursing, Infection Control RN, RN auditors, CPD, Radiology and pharmacy representation.
To monitor performance and ensure the problem does not reoccur an attendance record will be maintained and those in attendance. Those not in attendance or excused from the meeting will be reflected in the minutes.
This correction will be implemented and completed no later than 2/19/2024.
The Director of Nursing will monitor and be responsible for continued compliance.
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