Initial Comments:
This report is the result of a State licensure survey conducted on January 12, 2024, at Reading Hospital Surgicenter At Spring Ridge. 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:
555.22 (c)(1-5) LICENSURE
Surgical Services - Preoperative Care
Name - Component - 00
555.22 Pre-operative Care
(c) Written instruction for preoperative procedures, which have been approved by the medical
staff, shall be given to the patient or responsible person, and shall include:
(1) Applicable restrictions upon food and drink before surgery
(2) Special preparations to be made by the patient
(3) The required proximity of the patient to the ASF for a specific time following surgery if applicable.
(4) An understanding that the patient may require admission to the hospital in the event of medical need.
(5) The requirement that, upon discharge of a patient who has received sedation or general anesthesia, a responsible person shall be available to escort patient home. With respect to patients who receive local or regional anesthesia, a medical decision shall be made regarding whether such patients require a responsible person to escort them home.
Observations:
Based on a review of facility policy, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to provide documentation that written preoperative instructions were given to patients for 1 out of 10 medical records reviewed (MR1).
Findings include:
On January 12, 2024, at approximately 1:00 PM a review of facility's policy titled "Criteria and General Policies for Admission" with a revision date of January 2022, revealed "The patient should be given SurgiCenter patient information paperwork at the physician's office when surgery is scheduled. This paperwork notes important preoperative instructions for the patient as well as regulatory education materials."
On January 12, 2024, at approximately 11:00 AM a review of medical records revealed MR1 did not contain documentation that written preoperative instructions were provided to the patient.
On January 12, 2024, at approximately 11:15 AM an interview with EMP1 confirmed that the medical record did not contain any documentation that written preoperative instructions were provided to the patient.
Plan of Correction:The ASF will provide a communication to the surgeons offices reminding them to please provide our written pre operative instructions at the pre operative visit. to be completed 2/20/2024
Pre operative staff will be re-educated on verifying and charting that the patient was provided our written pre operative instructions. This will be completed with in person staff meeting over the next week.
50 chart audits per month will be done for the month of March, April and May 2024 to ensure compliance. Audit will be extended if audit does not show 100% compliance.
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