This report is the result of an unannounced revisit survey conducted on January 11, 2020, and March 8, 2021, following a State Licensure survey completed on September 11, 2020, at 20/20 Surgery Center. It was determined that 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:
555.24 (a) LICENSURE
Surgical Services - Postoperative Care
Name - Component - 00
555.24 Postoperative Care
(a) The findings and techniques of an operation shall be accurately and completely written or
dictated immediately after procedure by the practitioner medical staff member who performed the operation. If a physician assistant or certified registered nurse practitioner performed part of the operation, the findings and techniques of the procedure shall be accurately and completely recorded and the report shall be countersigned by the medical staff member. This description shall become a part of the patient's medical record.
Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure the findings and techniques of an operation were accurately and completely written or dictated immediately after the procedure by the practitioner medical staff member who performed the operation for four of ten medical records reviewed (MR5, MR7, MR8 and MR9).
Review on March 8, 2021, of the facility's "Operative Report" policy, which was last reviewed by the facility on October 19, 2020, revealed: "... Procedures I. The findings and techniques of an operation should be accurately and completely documented immediately after the procedure and authenticated by the healthcare practitioner who performed the operation. ... " .
1)Review of MR5's electronic medical record revealed that MR5 presented to the facility for a Selective Laser Trabeculoplasty (SLT) procedure. However, the operative reported incorrectly indicated that MR5 completed a yttrium-aluminum-garnet (YAG) procedure. In addition, the medical record showed the procedure as being completed on January 13, 2021, at 10:28 AM, and the operative report was completed on January 13, 2021, at 10:12 AM (the operative report preceded completion of the procedure) .
2)Review of MR7's electronic medical record revealed a YAG procedure was completed on January 13, 2021 at 10:11 AM, and the operative report was completed on January 13, 2021 at 10:00 AM.
3)Review of MR8's electronic medical record revealed a YAG procedure was completed on January 13, 2021, at 10:33 AM, and the operative report was completed on January 13, 2021, at 10:12 AM.
4)Review of MR9's electronic medical record revealed a YAG procedure was completed on January 13, 2021, at 10:11 AM, and the operative report was completed on January 13, 2021, at 10:13 AM.
During an interview on March 8, 2021, at approximately 9:40 AM, EMP1 confirmed the above for MR5.
During an interview on March 8, 2021, at approximately 10:58 AM, EMP1 confirmed the above for MR7, MR8, and MR9.
Plan of Correction:
The surgery center shall have the physician clearly document the findings and technique of an operation accurately and completely in writing in the medical records immediately after performing the procedure, effective immediately.
The administrator will ensure that patient charts are monitored by the Director of Nursing for completeness on a daily basis.
Changes are in place today (March 15, 2021). The Administrator and Director of Nursing will assess compliance of these changes on April 30, 2021 for implementation of this plan of correction to come into complete compliance.
The Administrator will expect 100% compliance with the requirements. The Administrator and Director of Nursing will continue to monitor all medical records for complete compliance.
These changes in charting and chart monitoring will be reviewed by the Quality Committee and the Governing Board
557.3 (a) LICENSURE
QA & Improvement Program
Name - Component - 00
557.3 The Quality Assurance and Improvement Program
(a) The quality assurance program shall include monitoring and evaluation of data collected, based on defined criteria that reflect current knowledge and clinical experience and relate to the care provided by the service. Sources of data include the medical records, incident reports, infection control records and patient complaints. The medial record shall contain sufficient data to support the diagnosis and determine that the procedures are appropriate to the diagnosis. Facilities that treat pediatric patients shall segregate data regarding such patients.
Based on review of facility documents and staff interview (EMP), it was determined the facility continued to fail to assure that contracted services were provided in a safe and effective manner.
Review of facility policy, "Quality Management Plan, Revision date September 29, 2020," revealed, "Procedures...III. The plan shall emphasize the ongoing nature of the quality assurance program and the comprehensiveness of the scope of the program which shall include monitoring and evaluation of the following:...i. Contracted services, quarterly."
A review of the facility list of contracted services revealed a total of 13 contracts.
A review of quality data since the last survey failed to include contracted services, including but not limited to ambulance transfer, housekeeping services, laboratory services, linen services, and pharmacy services.
A review of the most current quarterly quality committee meeting minutes, dated January 29, 2021, failed to address any quality being reviewed for contracted services.
During an interview on March 8, 2021, at 10:20 AM, EMP1 confirmed the facility is not presently looking at quality for the facility's contracted services.
Plan of Correction:
The Administrator will make certain that all contracted services are monitored and evaluated accordingly. Data will be collected by staff , medical record audits, patient surveys, incident reports , and infection control records.
Facility policy has already been updated to include
G. Improvement activities
5. Contracted Services,
Plan of corrections was initiated today (March 15, 2021). The assessment will include all Contracted Service evaluation from January 1, 2021. The results of this evaluation will be reported to the Quality Committee meeting in April 2021 and at a Special meeting of the Governing Board before April 30, 2021. This shall allow for substantial compliance effective 60 days from day of exit.
The Administrator will only accept 100% compliance with the requirements and will continue to monitor after completion date.
The change will ensure that the Contracted Services with be monitored and evaluated quarterly and reviewed by the Quality Committee and the Governing Board