Initial Comments:
This report is the result of an off-site special monitoring survey conducted on March 7, 2024, for Central Chester County Endoscopy. 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:
51.4 (a) LICENSURE
Change in Ownership/Management
Name - Component - 00
51.4. Change in ownership; change in management.
(a) A health care facility shall notify the Department in writing at least 30 days prior to transfer
involving 5% or more stock or equity of the health care facility.
Observations:
Based on review of facility documents and email correspondence, it was determined the facility failed to provide at least a 30-day notice to the Department of Health (Department) prior to a change of ownership.
Findings include:
Review of a correspondence sent by the facility to inform the Department of a change in ownership, revealed the notification was dated March 7, 2024, for a change in ownership that was effective on January 1, 2023.
Review on March 7, 2024, of the Department's correspondence revealed the faciltiy did not notify the Department in writing 30 days prior to the transfer of stock or equity of the health care facility.
Email correspondence from EMP1 dated March 7, 2024, confirmed the change in ownership occurred at the facility on January 1, 2023, and a 30-day notice was not provided prior to the closing.
Plan of Correction:Central Chester County Endoscopy will correct deficiency #0015 related to the ASF not providing at least a 30-day prior notice of change of ownership to the Department of Health.
The ASF has conducted a board meeting with owners of the facility reviewing policy #2019 "Change in Ownership, Organization, Operations, or Quality of Care Events". Education was provided to owners on the policy and requirements. The ASF manager shall be responsible for ongoing monitoring and providing notification to the Department of Health for any change of ownership requirements. The ASF nurse manager shall require comment on any ownership changes, operation, or quality of care events at each quarterly Quality meeting and report to board accordingly at board meetings to ensure appropriate notifications are provided to the Department of Health and CMS. Currently the change of ownership documents are completed but waiting for CMS and PECOS required documents to be completed and accepted to send to the Department of Health with the required application and documents. This plan of care shall be completed by 3/28/2024.
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