Initial Comments:
This report is the result of an unannounced revisit survey conducted on January 23, 2024, following a State Licensure survey completed on September 21, 2023, at Crozer - Keystone Surgery Center at Brinton Lake. 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:
553.3 (8) 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:
Observations:
Based on review of facility policy, credential files (CF) and staff interview (EMP), it was determined the facility failed to obtain current background checks for five of ten credential files reviewed (CF1, CF3, CF4,CF9, CF10).
Findings include:
Review on September 21, 2023, of the facility policy "Criminal Background Checks," revealed " ...In order to ensure compliance with the Patient Abuse Prevention Act ...Company conducts criminal background history checks, including Pennsylvania State Police Criminal History (PATCH), and FBI fingerprinting on all prospective employees as a condition of employment. In addition, Department of Public Welfare (DPW) Child History clearances are required on all hospital and physician practice employees. "
Review of credential files on January 23, 2024, revealed the following:
CF1 did not contain current Federal Bureau of Investigation (FBI) fingerprinting verifications.
CF3 did not contain current Federal Bureau of Investigation (FBI) fingerprinting verifications.
CF4 did not contain current Pennsylvania State Police Criminal History verifications.
CF9 did not contain current Federal Bureau of Investigation (FBI) fingerprinting verifications.
CF10 did not contain current Pennsylvania State Police Police Criminal History verifications.
Interview with EMP1 on January 23, 2024, confirmed the above findings. EMP1 was asked to show monthly audits that were reported to Quality Care Committee. EMP1 could not provide the information requested.
Plan of Correction:TThe Director of Medical Staff Affairs or a designee will ensure that all current Brinton Lake Surgery Center providers have the required background checks completed per hospital policy by 3/22/2024. All audit data will be reported monthly to the Quality of Care Committee by the Director of Medical Staff Affairs or a designee until all provider clearances have been obtained.
The Chief Medical Officer is ultimately responsible for this plan of correction.
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