This report is the result of a State licensure survey conducted on March 4-5, 2021, at Advanced Center for Surgery, LLC. 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
Governing Body responsibilities include:
(1) Conforming to all applicable Federal, State, and local laws.
Based on a review of facility documents and interview with facility staff (EMP) it was determined that the facility failed to conform to all applicable State Laws.
Advanced Center for Surgery, LLC was not in compliance with the following State Law related to Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) ACT, 40 PS.1303.302.
Section 310. Patient safety committee. (a) Composition. ... (2) An ambulatory surgical facility's or birth center's patient safety committee shall be composed of the medical facility's patient safety officer and at least one health care worker of the medical facility and one resident of the community served by the ambulatory surgical facility or birth center who is not an agent, employee or contractor of the ambulatory surgical facility or birth center. No more than one member of the patient safety committee shall be a member of the facility's board of governance. The committee shall include members of the medical facility's medical and nursing staff. The committee shall meet at least quarterly.
This was not met as evidenced by:
Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to follow their adopted Patient Safety Plan by failing to ensure that Patient Safety Committee meetings were conducted quarterly for 2020.
Review of Risk Management and Patient Safety Policy, reviewed 2020, revealed, "... Establish a Patient Safety Committee and accountable to: ... The Patient Safety Committee will meet at least quarterly as designated ... ."
A request was made to review Patient Safety Committee meeting minutes.
Review of meeting minutes entitled "Patient Safety/Infection Control Committee Minutes" dated February 25, 2020, and August 18, 2020, was conducted.
An interview with EMP1 on March 5, 2021, at approximately 11:00 AM confirmed that only two meetings were conducted in 2020.
Plan of Correction:
Based on Advanced Center for Surgery's Medical Staff Bylaws all Patient Safety/Infection Control quarterly meetings will be completed on a yearly basis using all means necessary including a Virtual option if necessary to maintain compliance with the State Law related to Act 13.
Minutes will reflect that all Quarterly Patient Safety/Infection Control meetings were completed. All Patient Safety/Infection Control minutes will be documented, reviewed and discussed at the QI and Board Level.