QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
Health Inspection Results For:

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Initial Comments:

This report is the result of an unannounced revisit survey conducted on April 23, 2021, following a State Licensure survey completed on December 17, 2020, at Elite Surgery Center, LLC. It was determined that 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:

555.3 (d)(1-2) LICENSURE

Name - Component - 00
Granting of clinical privileges shall follow established policies and procedures in the bylaws or similar rules and regulations the procedures shall provide the following.
(1) Written record of the application, which includes the scope of privileges sought and granted. The delineation "clinical privileges"shall address the administration of anesthesia.
(2) A review, summarized on record with appropriate documentation of the qualifications of the applicant.

Based on a review of facility documentation, credential files (CF), and staff interview (EMP), it was determined the facility continued to fail to follow their medical staff bylaws for the reappointment process for two of ten credential files reviewed (CF6, & CF9).

Findings include:

On April 23, 2021, a review of the facility "Medical Staff Bylaws," revised 2/5/2019, revealed, "Article III Medical Staff Membership...Section E - Reappointment Process...2. At appropriate intervals, the Credentialing Committee shall review all pertinent information required of or available on each practitioner for the purpose of determining recommendations for reappointment to the Staff and/or renoewal or change of privileges for the ensuing reappointment...Article IV Privileges Section A - Delineation of Priveilges 1. Every practitioner practicing at the Elite Surgery Center, by virtue of Staff membership shall, in connection with such practice, be entitled to exercise only those privileges specifically granted by the Governing Body."

A review of CFs was completed on April 23, 2021. Review of CF6 and CF9 revealed no documented evidence that the requested privileges were either approved or denied.

During an interview on April 23, 2021, at 9:50 AM, EMP1 confirmed the above findings stating that the approved boxes next to the requested privileges "should be checked approved."

Plan of Correction:

1. Credentialing: Correct Deficiency by the following measures:

a. Correct current CF 2-3-5-6-7-8-9 credential files to ensure chosen credentials are approved.
b. Review of credential files by assigned personnel.
c. Review Privilege request application upon receipt.
d. Monthly spreadsheet/checklist compiled and reviewed monthly.
e. Upon credentialing/ re-application files reviewed for completeness prior to approval of file by designated personnel. Checklist will be assigned and reviewed by designated personnel.
f. Signature obtained for granted privileges with approval by Medical Director.
g. Credential deficiencies will be reviewed and reported on quarterly QI documentation notes.
h. Director of Nursing is responsible for the plan of correction.

555.22 (c)(1-5) LICENSURE
Surgical Services - Preoperative Care

Name - Component - 00
555.22 Pre-operative Care

(c) Written instruction for preoperative procedures, which have been approved by the medical
staff, shall be given to the patient or responsible person, and shall include:
(1) Applicable restrictions upon food and drink before surgery
(2) Special preparations to be made by the patient
(3) The required proximity of the patient to the ASF for a specific time following surgery if applicable.
(4) An understanding that the patient may require admission to the hospital in the event of medical need.
(5) The requirement that, upon discharge of a patient who has received sedation or general anesthesia, a responsible person shall be available to escort patient home. With respect to patients who receive local or regional anesthesia, a medical decision shall be made regarding whether such patients require a responsible person to escort them home.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility continued to fail to ensure written preoperative instructions were provided for ten of ten medical records (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10).

Review of facility policy, "Pre-Admission Policy" revised May 20, 2019, revealed, "II. The Preop assessment, teaching/instructions and pre-procedural care will be complete prior to admission to the Elite Surgery Center."

A review was completed on April 23, 2021, and revealed that MR1 had no documentation the patient was provided with written pre-op instructions.

A request was made for EMP1 to show surveyor EHR (electronic health records) of MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, and MR10. EMP1 stated that none of the medical records had the new form to verify that patients received written preoperative instructions. Further interview on April 23, 2021, at 10:10 AM revealed that the "EHR company" hasn't implemented the "new HIPPA" form where the patient will sign that they received the written instructions. EMP1 stated she had asked her nurses to sign in the record that the patient verified receiving the written instructions but "they aren't documenting that."

Plan of Correction:

2. Pre-operative written instructions: Correct deficiency by the following measures:

a. Written instructions will be provided by the providers office.
b. Verification of written instructions to the patient by the pre-admit nurse on pre-op assessment call interview.
c. Signature obtained from patient on Facility/ HIPPA form at registration.
d. Review of chart analysis will be performed on monthly QI and deficiencies reported quarterly.
e. Director of Nursing is responsible for the plan of correction.