Initial Comments:
This report is the result of an unannounced special monitoring survey completed on May 23, 2023, at North Shore Endoscopy Center. It was determined that 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:
553.31 (a) LICENSURE
Administrative responsibilities
Name - Component - 00
A full time person in charge shall be appointed who has authority and responsibility for the operation of the ASF at all times. Qualifications, authority, responsibilities and duties of the person in charge shall be defined in a written statement adopted by the governing body.
Observations:
Based on review of a facility documents and staff interviews (EMP), it was determined the facility failed to ensure a full-time person in charge of the surgery center at all times.
Findings include:
Review of a document dated May 1, 2023, revealed the facility requested an exception to 28 Pa. Code 553.31(a) Administrative responsiblities. The exception was denied.
Review of a letter provided to the Department of Health on May 9, 2023, revealed two nurses would share the responsibility for the daily operational (Administration) oversight of the facility. The letter also indicated the the previous administrator assumed the administrator role at another facility as of April 10, 2023.
At the time of the review, EMP1 confirmed there was no full time person in charge. EMP1 further confirmed two nurses were sharing the responsiblities of the administrator.
Plan of Correction:On April 10, 2023, the administrator for this facility took a position at another in-network facility leaving a vacancy. While advertising for the full-time administrator position an exception was requested and denied. In the interim, the DON and a charge nurse were providing daily operational oversight in the administrator role. The outgoing administrator's new role was in the network for a facility that was just opening, this administrator was available as a resource during this time. The new administrator assumed the role on June 12, 2023. The role was then again vacated on September 29th, 2023. A plan was put into place during that time with the DON assuming the role of administrator and detailing the roles' coverage if he/she could not be onsite. The exception was again requested September 19, 2023 but the paperwork did not go through at that time. The exception was then resubmitted and subsequently discussed at the November exception committee meeting and granted. The role of the administrator will be evaluated at each yearly board meeting. If sharing this role creates a hardship for either facility the quality committee will bring forth the issues to the Board of Directors.
|