QA Investigation Results

Pennsylvania Department of Health
EDGEWOOD SURGICAL HOSPITAL
Health Inspection Results
EDGEWOOD SURGICAL HOSPITAL
Health Inspection Results For:


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Initial Comments:

This report is the result of an offsite special monitoring survey concluded on March 10, 2020, at Edgewood Surgical Hospital. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 Pa Code, Part IV, Subparts A and B, November 1987, as amended June 1998.




Plan of Correction:




109.2 (b) LICENSURE
DIRECTOR OF NURSING SERVICES

Name - Component - 00
109.2
(b) The director of nursing services shall be employed on a full time basis and shall be responsible to the chief executive officer or his designee for developing and implementing policies and procedures of the service.

Observations:

Based on review of the Department of Health's (Department) database, it was determined that the facility failed to ensure the Director of Nursing Services was employed on a full-time basis at the facility.

Findings include:

Review, at approximately 11:30 AM on March 10, 2020, of the Department database for Edgewood Surgical Hospital revealed EMP1 to be identified as the full-time Director of Nursing. Further review revealed the document to be signed by the facility CEO as being complete on November 18, 2019.

Review, at approximately 11:32 AM on March 10, 2020, of the Department Ambulatory Surgical Facility Application Request form for OTH1 revealed EMP1 to be identified as the Director of Nursing. Further review revealed the document to be signed by the facility CEO as being complete on September 30, 2019.







Plan of Correction:

Edgewood Surgical Hospital will submit an exception for a full-time DON to be shared at both facilities. In the meantime, Lawrence County Surgery Center is currently closed as part of the implementation of its Emergency Preparedness Plan in response to the COVID-19 virus.