This report is the result of a State Re-licensure survey conducted on April 11, 2022 , at Bryn Mawr Medical Specialist Endoscopy. 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
Governing Body responsibilities include:
(1) Conforming to all applicable Federal, State, and local laws.
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to applicable State laws.
Bryn Mawr Medical Specialist Endoscopy, was not in compliance with the following State law:
Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act 40 P.S.
Patient safety committee. Section 310. Patient safety committee. ... (2) An ambulatory surgical facility's or birth center's patient safety committee ... No more than one member of the patient safety committee shall be a member of the medical facility's board of governance ..."
This is not met as evidenced by:
Based on review of facility documents, policies and procedures, and interviews with Staff (EMP), it was determined the facility failed to ensure only one member of the facility's Governing Body was a member of the facility's Patient Safety Committee (EMP1, EMP2, EMP3, EMP4, and EMP5)
Review on April 11, 2022, of facility document "Bryn Mawr Medical Specialist Endoscopy Committee Roster List", no date, revealed there were five members listed on the Governing Body Committee list who were also listed on the Patient Safety Committee list (EMP1, EMP2, EMP3, EMP4 and EMP5).
Review on April 11, 2022 of facility policy "Patient Safety Plan", no date, revealed "The Patient Safety Committee will be comprised of the: Patient Safety Office, Members of the facility's medical and nursing staff, one resident of the community served by the Ambulatory Surgical Center.... " Further review confirmed the Patient Safety Plan did not address the preclusion of more than one member of the Governing Body from being members of the Patient Safety Committee.
Review on April 11, 2022, of the facility's Patient Safety Committee meeting minutes for the first quarter 2022, revealed EMP1, EMP2, EMP3, EMP4, EMP5 all attended this Patient Safety Meeting.
Email Interview with EMP6, on April 27, 2022, at 10:26 AM, confirmed there was more than one Governing Body Board member on the facility's Patient Safety Committee. EMP6 further confirmed that EMP1, EMP2, EMP3, EMP4 and EMP5 were all on the facility's Governing Board and the facility's Patient Safety Committee.
Plan of Correction:
The Administrative Director has reviewed the PA MCARE Act 13 and acknowledges this deficiency. The corrective action is as follows:
Review of the current Policies and Procedures GOV# 4 reveals the current list of members of the patient safety committee includes 5 members who are also members of the governing body. The administrative Director will revise Policies and Procedures GOV# 4 with the new list of patient safety committee members in compliance with MCARE Act 13, removing all governing body members except the Medical Director. The Administrative Director will also revise the patient safety plan, under heading Committee Composition, "No more than one member of the patient safety committee shall be a member of the facility's governing body."
The Administrative Director will meet with the governing body to discuss the plan of corrections so all members of the governing body are educated to the stipulations set forth in MCARE Act 13, regarding Patient Safety committee membership. The governing body will review and approve the new list of patient safety committee members (GOV# 4) proposed by the Administrative Director. The governing body will also review and approve the revisions made under the Committee Composition guidelines of the Patient Safety Plan.
To continually protect the patient community served by the facility and to ensure the problem does not recur, the revised patient safety plan will be monitored by the patient safety officer and reviewed and approved annually by the governing body to ensure all committee members are in compliance with the guidelines set by MCARE Act 13.
The Administrative Director and Governing Body are responsible for this plan of corrections. This plan of corrections will be completed by May 31, 2022.