Initial Comments:
This report is the result of a State licensure survey conducted on August 8, 2023, at Crozer Endoscopy Center. 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
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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 (EMP1), it was determined the facility failed to conform to all applicable State Laws.
The facility was found to be non-compliant with the following State Law "Medical Care Availability and Reduction of Error (MCARE) Act - Reduction and Prevention of Health Care - ACT of July. 20, 2007, P.L. 331, No. 52, Chapter 4, Health Care-Associated Infections ... Section, 403. Infection control plan ... (1) A multidisciplinary committee including representatives from each of the following ... (ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility ..."
Findings include:
Review of the facilities Infection Control Meeting Minutes revealed that on January 19, 2023, April 20, 2023, and July 13, 2023, no community member was present for the infection control committee meeting.
Interview with EMP2 on August 8, 2023, at approximately 11:00 AM confirmed the above findings.
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Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to all applicable State laws.
The facility was found to be non-compliant with the following State Law, Act 13 of 2002, Medical Care Availability and Reduction of error (MCARE) ACT, 40 ... "Section 310, Patient Safety Committee. (a) Composition. ... (2) An ambulatory surgical facility'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 ... who is not an agent, employee, or contractor of the ambulatory surgical facility ..."
Findings include:
Review of the facilities Patient Safety Meeting Minutes revealed that on January 19, 2023, April 20, 2023, and July 13, 2023, no community member was present for the patient safety committee meeting.
Interview with EMP2 on August 8, 2023, at approximately 11:00 AM confirmed the above findings.
Plan of Correction:The Patient Safety Committee and Infection Control Committee will meet by 10/13/23 to identify an appropriate and available community member for these committee meetings. Once identified, the resident of the community will be in attendance for all Patient Safety and Infection Control Committee meetings. In the event that the community member is unavailable or unable to attend the scheduled meeting, the Administrative Director will reschedule the meeting to a time when the community member can participate.
Attendees of the Patient Safety and Infection Control Committee meetings will be recorded within the meeting minutes and reviewed on a quarterly basis by the Administrative Director of Brinton Lake Endoscopy. The Administrative Director of Brinton Lake Endoscopy will ensure that 100% compliance has been achieved by the community member.
The Administrative Director of Brinton Lake Endoscopy will report the audit results to the Regulatory Affairs Department and the Senior Administrative Director of Ambulatory Services.
The Administrative Director of Brinton Lake Endoscopy is ultimately responsible for this plan of correction.
553.25 (1-6) LICENSURE
Discharge Criteria
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553.25 Discharge Criteria
A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.
Observations:
Based on a review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure discharge orders were written prior to discharge from the ambulatory surgery center for 6 out of 10 MR reviewed (MR2, MR4, MR5, MR7, MR9, MR10)
Findings include:
A review of facility policy "Discharge Criteria, Instructions, and Post-op Phone Call" effective July 13, 2015, revealed "... The following criteria are indicators that suggest readiness for departure of an ambulatory patient from the endoscopy center, unless otherwise indicated by the physician ... 4. Patients shall be discharged only on the written signed order of a practitioner ..."
Review of MR2 on August 2, 2023, revealed no documentation of a written discharge order prior to discharge from the facility.
Review of MR4 on August 2, 2023, revealed no documentation of a written discharge order prior to discharge from the facility.
Review of MR5 on August 2, 2023, revealed no documentation of a written discharge order prior to discharge from the facility.
Review of MR7 on August 2, 2023, revealed no documentation of a written discharge order prior to discharge from the facility.
Review of MR9 on August 2, 2023, revealed no documentation of a written discharge order prior to discharge from the facility.
Review of MR10 on August 2, 2023, revealed no documentation of a written discharge order prior to discharge from the facility.
An interview conducted on August 8, 2023, at approximately 10:30 AM with EMP2 confirmed the above findings for MR2, MR4, MR5, MR7, MR9, and MR10.
Plan of Correction:The Administrative Director of Brinton Lake Endoscopy will ensure that 100% of available Brinton Lake Endoscopy Clinical Staff will be re-educated on the policy titled "Discharge Criteria, Instructions, and Post-op Phone Call" which details the requirement to ensure a discharge order is completed. Education will be completed by 10/6/23.
The Administrative Director of Brinton Lake Endoscopy or a designee will complete a minimum of 5 chart audits per week to ensure discharge orders are being entered per hospital policy. Any identified instance of noncompliance will be immediately addressed with the staff identified and reported to the Senior Administrative Director of Ambulatory Services. Audits will continue until three consecutive months of 100% compliance has been achieved. All audit data will be reported monthly to the Quality of Care Committee by hospital leadership.
The Administrative Director of Brinton Lake Endoscopy is ultimately responsible for this plan of correction.
555.24 (g) LICENSURE
Surgical Services - Postoperative
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555.24 Post Operative Care
(g) Patients shall be discharged only upon the written signed order of a practitioner.
Observations:
Based upon review of facility documents, medical records (MR), and interview of staff (EMP) it was determined that the facility failed to assess each patient for bleeding prior to discharge for 8 out of 10 MR reviewed (MR2, MR3, MR4, MR5, MR7, MR8, MR9, MR10).
Findings include:
A review of facility policy "Discharge Criteria, Instructions, and Post-op Phone Call" effective July 13, 2015, revealed "... The following criteria are indicators that suggest readiness for departure of an ambulatory patient from the endoscopy center, unless otherwise indicated by the physician... E. Assess for bleeding ..."
Review of MR2 on August 2, 2023, revealed no documentation that nursing staff assessed the patient for bleeding prior to discharge from the facility.
Review of MR3 on August 2, 2023, revealed no documentation that nursing staff assessed the patient for bleeding prior to discharge from the facility.
Review of MR4 on August 2, 2023, revealed no documentation that nursing staff assessed the patient for bleeding prior to discharge from the facility.
Review of MR5 on August 2, 2023, revealed no documentation that nursing staff assessed the patient for bleeding prior to discharge from the facility.
Review of MR7 on August 2, 2023, revealed no documentation that nursing staff assessed the patient for bleeding prior to discharge from the facility.
Review of MR8 on August 2, 2023, revealed no documentation that nursing staff assessed the patient for bleeding prior to discharge from the facility.
Review of MR9 on August 2, 2023, revealed no documentation that nursing staff assessed the patient for bleeding prior to discharge from the facility.
Review of MR10 on August 2, 2023, revealed no documentation that nursing staff assessed the patient for bleeding prior to discharge from the facility.
Interview with EMP2 on August 8, 2023, at approximately 11:00 AM confirmed the above findings for MR2, MR3, MR4, MR5, MR7, MR8, MR9, and MR10.
Plan of Correction:The Administrative Director of Brinton Lake Endoscopy will ensure that 100% of available Brinton Lake Endoscopy Clinical Staff will be re-educated on the policy titled "Discharge Criteria, Instructions, and Post-op Phone Call" which details the requirement to assess for bleeding postoperatively. Education will be completed by 10/6/23.
The Administrative Director of Brinton Lake Endoscopy or a designee will complete a minimum of 5 chart audits per week to ensure bleeding is assessed postoperatively per hospital policy. Any identified instance of noncompliance will be immediately addressed with the staff identified and reported to the Senior Administrative Director of Ambulatory Services. Audits will continue until three consecutive months of 100% compliance has been achieved. All audit data will be reported monthly to the Quality of Care Committee by hospital leadership.
The Administrative Director of Brinton Lake Endoscopy is ultimately responsible for this plan of correction.
569.32 LICENSURE
Fire Inspection
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569.32 Fire Inspection
The ASF shall request an annual inspection by its local fire
department.
Observations:
Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to request an annual inspection by its local fire department.
Findings include:
Review conducted on August 8, 2023, of the facility's Fire Response Plans, last edited January 22, 2016, revealed the policy did not address an annual inspection by its local fire department.
Interview with EMP1 on August 8, 2023, at approximately 11:00 AM confirmed the facility did not request an annual inspection by its local fire department. Further interview with EMP1 revealed that the facility did not have a policy to address the request for an annual inspection by the local fire department.
Plan of Correction:The Administrative Director Brinton Lake Endoscopy will be coordinating an annual inspection with the Fire Marshall to be completed by the Concord Township.
The Administrative Director of Brinton Lake Endoscopy will be provided education related to the Pennsylvania Department of Health Regulation requirement to request an annual inspection by the local fire department. Education will be completed by 10/6/2023.
The Administrative Director will notify the Emergency Preparedness Coordinator when this request is made annually.
The Administrative Director of Brinton Lake Endoscopy is ultimately responsible for this plan of correction.
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