QA Investigation Results

Pennsylvania Department of Health
CENTER FOR SPECIALIZED SURGERY, L.P., THE
Health Inspection Results
CENTER FOR SPECIALIZED SURGERY, L.P., THE
Health Inspection Results For:


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Initial Comments:

This report is the result of a State Re-licensure survey conducted on April 7, 2022 and completed April 8,2022, at Center for Specialized Surgery, L.P. 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 (1) LICENSURE
Governing Body Responsibilities

Name - Component - 00
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.


Observations:
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to all applicable State laws.

Center for Specialized Surgery, L.P. was not in compliance with the following State law:

"Act 52 of 2007, Medical Care Availability and Reduction of Error (MCARE) Act Chapter 4. Health Care-Associated Infections 40 P.S.1303.403. Infection control plan (a) Development and Compliance. - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include: (1) A multidisciplinary committee ..."

This is not met as evidenced by:

Based on review of facility documents and interview with staff (EMP), it was determined the facility did not have a stand alone infection control committee for Center for Specialized Surgery Center.

Findings include:

Review on April 7, 2022, of the "Infection Control Committee" meeting minutes, dated January 2022, revealed the facility's infection control committee was combined with Quality Assurance Committee Meeting. Further review of the minutes, revealed there were no stand alone infection control meeting minutes for Center for Specialized Surgery Center.


Interview on April 7, 2022, at 11:37 AM, with EMP1 confirmed the facility's infection control committee is not a stand alone committee and only meets when facility infections needed to be discussed.







Plan of Correction:

The Infection Control Committee will hold separately scheduled quarterly meetings effective May 23, 2022 per Act 52 of 2007, Chapter 4, Health Care-Associated Infections 40 P.S. 1303.403. These meetings will be held separately from other committee meetings and include separate minutes which will be kept in a binder in the Administrator's office. Committee members will include but are not limited to: Medical director; administrator; clinical manager; Infection control designee; and a staff nurse. The Infection Control Committee will report to the Governing Board during quarterly meetings. The activities of the Infection Control Committee will be monitored by the facility administrator and/or Clinical Manager.

Infection control quality assurance will be monitored though surveillance tools used in identifying and reporting infections as outlined in the Infection Control Plan. Infection control monitoring will continue to be done by the designated Infection Control Officer and be reported at the committee meetings on a quarterly basis. All findings will then be presented to the Governing Body as indicated above.


553.12 (b)(7) LICENSURE
Implementation

Name - Component - 00
553.12
(b) The following are the minimal provisions for the patient's bill of
rights:
(7) The patient has the right to good quality care and high
professional standards that are continually maintained and reviewed

Observations:


Based on observation, review of facility policies and procedures, personnel files (PF), and staff interview (EMP), it was determined that the facility failed to ensure patients have the right to good quality care and high professional standards, that are continually maintained and reviewed, specific to staff being able to demonstrate how to use the Automated External Defibrillator (AED).

Findings include:

Observation on April 7, 2022 at 10:45 AM revealed EMP3 was not able to successfully demonstrate how to function the AED machine.

Review of facility policy and procedure "Initial and Annual Education", no date revealed, " a. Orientation/Education shall include but not be limited to: ii. Within 30 days of hire 10. patient care emergencies... b. Annual education will include, at least the following. i. will include the above topics listed above;..."

Review of PF3 personnel file on April 7, 2022 "Registered Nurse-Pre OP/PACU Job Description revealed, "Must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of patients served in the Center..."

Interview on April 7, 2022 at 10:46 AM with EMP2 confirmed the above observation and that the staff member is expected to know how to use the AED machine.







Plan of Correction:

Effective 5/22/2022, the clinical manager will ensure that all newly hired clinical staff members receive initial education within 30 days of hire on the function and use of emergency equipment. Additionally, current clinical staff will receive an in-service which is scheduled for June 23, 2022. Annual education on the function and use of emergency equipment will be completed by all staff going forward as part of annual competencies. All education reviewed will include all required components with return demonstration from the employee. Education will include review of equipment and supplies needed in the event of an emergency for various age groups served by our facility.