QA Investigation Results

Pennsylvania Department of Health
BERKS AMBULATORY SURGERY CENTER, LLC
Health Inspection Results
BERKS AMBULATORY SURGERY CENTER, LLC
Health Inspection Results For:


There are  28 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
This report is the result of a State licensure survey conducted on June 4, 2023, at Berks Ambulatory Surgery Center, LLC. 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:




567.3 (b) (11) LICENSURE
Policies and Procedures

Name - Component - 00
567.3 Polcies and procedures

(b) Current written policies and procedures to assure definite and
valid infection control shall include,but not be limited to, the
following:
(11) Staff health status requirements

Observations:

Based on review of facility policies, facility Personnel Files (PF), and staff interviews (EMP), it was determined that the facility failed to complete annual TB Risk Assessments per facility policy in eight out of eight PF reviewed (PF8, PF9, PF10, PF11, PF12, PF13, PF14 and PF15).
Findings Include:
Review on June 4, 2024 of facility policy "Employee Health Screening" with an effective date of December 12, 2019, revealed "1. TB Screening ... All employees will complete an annual TB Risk Assessment as developed by the CDC ..."
Review of PF8 on June 4, 2024, revealed the most recent document "Annual Tuberculosis (TB) Screening Questionnaire" was dated May 22, 2023.
Review of PF9 on June 4, 2024, revealed the the most recent document "Annual Tuberculosis (TB) Screening Questionnaire" was dated March 27, 2023.
Review of PF10 on June 4, 2024, revealed the most recent document "Annual Tuberculosis (TB) Screening Questionnaire" was dated February 2, 2023.
Review of PF11 on June 4, 2024, revealed no documented evidence the employee completed an annual TB Risk Assessment in the 2023 calendar year or 2024 to date.
Review of PF12 on June 4, 2024, revealed no documented evidence the employee completed an annual TB Risk Assessment in the 2023 calendar year or 2024 to date.
Review of PF13 on June 4, 2024, revealed no documented evidence the employee completed an annual TB Risk Assessment in the 2023 calendar year or 2024 to date.
Review of PF14 on June 4, 2024, revealed no documented evidence the employee completed an annual TB Risk Assessment in the 2023 calendar year or 2024 to date.
Review of PF15 on June 4, 2024, revealed the most recent document "Annual Tuberculosis (TB) Screening Questionnaire" was dated February 2, 2023.
Interview with EMP26 on June 4, 2024, at approximately 1:30 PM confirmed the TB Risk Assessments were not completed annually as required by facility policy for PF8, PF9, PF10, PF11, PF12, PF13, PF14 and PF15.





Plan of Correction:

As a component of its Infection Control Policies, the Center has adopted health screening policies of all employees to protect staff, family members and patients from exposure to serious diseases. All employees will complete an annual TB Risk Assessment as developed by the CDC. This questionnaire will be completed each year during time of annual review, along with the Health Statement.

The Infection Control Preventionist is responsible for distributing the questionnaire, reviewing responses and determining if any further medical evaluation is indicated. Both the Risk Assessment Questionnaire and a subsequent TB screening form, if required, will be returned to the ICP for review and evaluation. Upon completion of certification and review, the Center Administrator will file the TB screening form in the employee's health record.

All employee TB Risk Assessment Questionnaires for the current year will be completed by June 30, 2024. The Center Administrator will be responsible for verifying that this has been completed as scheduled.