This report is the result of an onsite State licensure survey conducted on August 27, 2020, at Cornerstone Ambulatory Surgery Center LLC. It was determined the facility was 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:
Based on the findings of a state re-licensure survey conducted on August 27, 2020, Cornerstone Ambulatory Surgery Center, was found to be non-compliant with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.
(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Based on a review of facility policies, documents, observation and interview with staff (EMP), it was determined that the facility failed to conform to all applicable State laws.
The Cornerstone Ambulatory Surgery Center LLC was not in compliance with the following State law related to Act 110 of November 23, 2010, and subsequent provisions effective June 1, 2015, Health Care Facilities Act PHOTO IDENTIFICATION TAG REGULATIONS.
"HEALTH CARE FACILITIES ACT 110 Clarification Notice: PHOTO IDENTIFICATION REGULATION" revealed "In the notice published at 45 Pa. B. 2427 (May 16, 2015), the department of health (Department) provided notice relating to the provisions of section 809.2 of the Health Care Facilities Act (35 P.S. 448.809 b), enacted by the act of November 23, 2010, (P.L. 1099, No 110), that would become effective June 1, 2015.
Section 54.2 Requirements
(b) As of June 1, 2015, an employee who delivers direct care in a health care facility and an employee of a physician practice group owned and operated by a health care provider shall wear a photo identification badge that meets the requirements of .54,3,
. 54.3 Contents of photo identification badge
(a) The photo identification badge shall include all of the following: (1) A recent photograph of the employee, updated as provided for in subsection (c). (2) The employee's full name. (3) The employee's title as required by 54.4. (4) The name of the employee's health care facility or employment agency.
(a) The photo identification badge shall contain the title of the employee. (b) The title shall be the complete designation contained on the professional license, certification or registration of the employee. (c) If the employee does not possess a professional license, certificate or registration, the title shall be the designation which most accurately describes the employee's job function. (d) The title shall not be abbreviated. (e) The title of the employee or physician shall be in block type and shall occupy a one-half inch tall strip as close a practicable to the bottom edge of the badge. (f) This section shall take effect on June 1, 2015.
This is not met as evidenced by:
Based on observation, and review of facility policies, and interview with staff (EMP), it was determined the facility failed to ensure that staff was provided with appropriate identification badges to wear as required by law.
Observation on August 27, 2020, at 9:20 AM of EMP2 identification badge revealed the badge title was not in block type and did not occupy a one-half inch tall strip as close proximity to the bottom edge of the identification badge as possible. Further observation revealed the identification badge did not include a recent photograph of the employee.
A review on August 27, 2020, of facility policies failed to reveal a policy for employee identification badge requirements.
Interview with EMP1 on August 27, 2020, revealed EMP2 did not have an identification badge that included their photograph or required format.
Plan of Correction:
In compliance with 35 P. S. § 448.809b LICENSURE Photo Id Reg: The center will comply with the standard by October 30, 2020. Each employee will have their picture, name, title, and facility name printed on their ID tag to be in accordance with the photo identification specification and regulations.
The Director of Nursing will be responsible to ensure all employees have Employee Picture Identification Badges. The Director of Nursing will ensure the employee badge are accurate and monitored yearly with their picture, name, title, and facility name printed on their ID badge. Employee Identification Picture Badge system will be discussed at our next staff meeting.