QA Investigation Results

Pennsylvania Department of Health
20/20 SURGERY CENTER, LLC
Health Inspection Results
20/20 SURGERY CENTER, LLC
Health Inspection Results For:


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Initial Comments:


This report is the result of a State licensure survey conducted on August 22, 2022, at 20/20 Surgery Center. 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 (8)(iii) LICENSURE
Governing Body Responsibilities

Name - Component - 00
553.3 Governing Body responsibilities include:
(8) Establishing personnel policies and practices which adequately support
sound patient care to include, the following:
(iii) Personnel records shall include current information relative to periodic work performance evaluations.



Observations:

Based a review of facility policy and facility documents and personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure periodic work performance evaluations were kept current for three of 10 personnel files reviewed (PF1, PF5, PF6)

Findings include:

On August 22, 2022, a review of the facility policy titled, "Professional Improvement," revision date, June 1, 2021, revealed, "Procedures I. The facility supports and provides professional competence and skills by:...Annually review [sic] employees' work performance, communicate and record utilizing an evaluation tool."

A review of facility personnel files was completed on August 22, 2022, and revealed the following:

PF1 was hired on January 15, 2021, no performance evaluation since hire,

PF5 was hired on July 22, 2019, last performance evaluation was dated July 13, 2021, not within the past year,

PF6 was hired on May 24, 2016, last performance evaluation was dated May 17, 2021, not within the past year.

During an interview on August 22, 2022, at 10:45 AM, EMP1 confirmed the expectation is for employees to be evaluated on an annual basis. Further interview confirmed that the above staff did not have current work performance evaluations.





Plan of Correction:

All personnel shall have work performance evaluation completed annually by the Director of Nursing or the Administrator.

A list of personnel will be complied to have a section for which the Director of Nursing and Administrator can review when work performance evaluation is due. All personnel files will be reviewed monthly to assure that all state requirements are up to date, and this shall include work performance evaluation.

The Plan of Correction shall be initiated immediately and expected to be in compliance by September 30, 2022.

The Administrator will only accept 100% compliance at that time and will continue to monitor after completion date.



555.3 (b) LICENSURE
Requirements

Name - Component - 00
Privileges granted shall reflect the results of peer review or utilization review programs, or both, specific to ambulatory surgery.

Observations:

Based on a review of facility documents and credential files (CF) and staff interview (EMP), it was determined that the facility failed to document the use of peer review information in reaching decisions for credentialing for six of six credential files reviewed (CF1, CF2, CF3, CF4, CF5, CF6), and failed to include peer review data two of six credential files reviewed (CR5, CR6).

Findings include:

On August 22, 2022, a review of the facility credential files revealed the following:

1. A review of the Clinical Review Committee meeting minutes from July 20, 2022, revealed, "....that there is no documentation demonstrating the use of peer review data in order to make recommendations to the governing body for credentialing medical staff."
2.A review of the Governing Board minutes from July 22, 2022, reveals that there is no documentation demonstrating the use of peer review data to consider candidates for medical staff membership.
3.A review of Medical Staff Bylaws (Last Revised: April 22, 2022), Section3.8- Procedure for Reappointment to Medical Staff revealed, "#4 ..To provide adequate medical records for peer review and quality assurance each surgeon is required to perform a total of 10 procedures at the Center during the previous twelve month period."
4.A review of credential files revealed no peer review data collected on CF5 and CF6, who were recommended by the Clinical Review Committee for medical staff membership on July 20, 2022 and received approval for medical staff membership by the governing body on July 22, 2022.
These findings were confirmed by EMP1 on August 22, 2022 at 10:18AM.







Plan of Correction:

All Medical Staff Members shall have documentation of peer review audit which will be used for decision making during reappointment.

The Administrator will develop a spreadsheet which will be used to ensure that all Medical Staff Members provide the Medical Director with all the appropriate documentation. The spreadsheet will include all the data the Medical Staff Bylaws require for reappointment. The Medical Director will present all documentation to the CRC during review of Medical Staff Member application for reappointment. Once approved by the CRC this information will be presented to the Board of Directors by the CRC Chairman.

Each Medical Staff Member will have 2 charts audited monthly (including CRNA) starting September 6, 2022. To ensure that the audits are complete they will be presented to the CRC quarterly meeting. an then all documentation will be presented to the CRC during review of Medical Staff Member application for reappointment. Once approved by the CRC this information will be presented to the Board of Directors by the CRC Chairman.

Plan of correction will be initiated immediately, and compliance will be ongoing. The Administrator will expect 100% compliance at the time of appointment/reappointment.




555.3 (f) LICENSURE
Requirements

Name - Component - 00
555.3 Requirements for membership and privileges.

(f) The governing body shall request and consider reports from the National Practitioner Data Bank on each practitioner who requests privileges.

Observations:

Based on a review of credential files (CF) and staff interview (EMP), it was determined that the facility failed to consider reports from the National Practitioner Database (NPDB) for six of six credential files reviewed (CR1, CF2, CR3, CR4, CR5, CR6).

Findings include:

1.On August 22, 2022, a review of CF1, CF2, and CF3 revealed that the NPDB had last been queried on June 12, 2021. Current re-appointment for CF1, CF2, and CF3 was approved by the governing body on July 22, 2022.
2.On August 22, 2022, a review of CF4, revealed that the NPDB had been queried on August 3, 2022, after the clinician had received approval for reappointment on July 22, 2022.
3.On August 22, 2022, a review of CF5 revealed that the NPDB had last been queried on April 21, 2021. Current re-appointment for CF5 was approved by the governing body on July 22, 2022.
4.On August 22, 2022, a review of CF6 revealed that the NPDB had last been queried in March of 2021. Current re-appointment for CF6 was approved by the governing body on July 22, 2022.

The above findings were confirmed by EMP1 on August 22, 2022 at 10:18am.





Plan of Correction:

The Administrator shall obtain a report from National Practitioner Database (NPDB) prior to appointment of new Medical Staff Member. For Medical Staff Members up for reappointment NPDB report will be obtained prior to reappointment.

The Administrator will develop a spreadsheet will be use to ensure that each Medical Staff Member will have all appropriate documentation required by the Medical Staff Bylaws for reappointment

NPDB report will be reviewed with all other documents required for appointment/reappointment by the CRC and Board of Directors

Plan of correction shall be initiated immediately, and compliance will be ongoing. The Administrator will obtain the NPDB report and will expect 100% compliance with each appointment/reappointment.



555.22 (a)(1-2) LICENSURE
Surgical Services - Preoperative Care

Name - Component - 00
555.22 Pre-operative Care

(a) Pertinent medical histories and physical examinations, and supplemental information regarding drug sensitivities documented day of surgery or one of the following:
(1) If medical evaluation, examination and referral are made from a private practitioner's office, hospital or clinic, pertinent records thereof shall be available and made part of the clinical record at the time the patient is registered and admitted tot he ASF. This information is considered valid no more than 30 days prior to the date of surgery.
(2) A practitioner shall examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The information shall be clearly documented in the medical record.



Observations:


Based on review of facility policies, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that medical histories and physical examinations were performed no more than 30 days prior to date of surgery for two out of ten medical records (MR5 and MR8).
Findings include:
Review of facility policy, titled "Medical Clearance" last revised on June 1, 2021, on August 22, 2022, revealed "...All patients scheduled for anesthesia services will be required to visit their PCP prior to the day of surgery to receive medical clearance for the procedure and proposed anesthesia. This shall be done no earlier than 30 days prior to the scheduled procedure date...".
On August 22, 2022, MR5, surgery date June 6, 2022, was reviewed and revealed a history and physical form was completed in office on April 18, 2022.
On August 22, 2022, MR8, surgery date June 20, 2022, was reviewed and revealed a history and physical form was completed in office on May 17, 2022.
EMP1 confirmed the above findings on August 22, 2022, at 9:20am. EMP1 explained at this time that when having both eyes done, it is not common practice for the facility to require a new history and physical even if the original falls outside of the 30 day window.





Plan of Correction:

All staff members will review and sign off on the Medical Clearance Policy 8.35

The Director of Nursing shall review patient charts to ensure all surgical patients scheduled for anesthesia shall have a medical clearance from their PCP dated no earlier than 30 days prior to the schedule surgery date, this shall be evaluated at the time of the pre-op phone call. Should another Registered Nurse make the pre-op call they will have reviewed and signed off on the Medical Clearance Policy and are aware that medical clearance has to be within 30 days of schedule procedure.

The Administrator will develop an audit for the Director of Nursing to complete on 5 charts per month for one year to ensure on going compliance.

Plan of Correction will be initiated immediately but not expected to be in complete compliance until October 24, 2022. The Director of Nursing and the Administrator will expect 100% compliance at that time.