QA Investigation Results

Pennsylvania Department of Health
AZURA SURGERY CENTER NORTHEAST PHILADELPHIA
Health Inspection Results
AZURA SURGERY CENTER NORTHEAST PHILADELPHIA
Health Inspection Results For:


There are  6 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
This report is the result of a State licensure survey conducted on March 03, 2021, at Azura Surgery Center Northeast Philadelphia. 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:




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.


Observations:
Based on a review of facility policies, medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide patients or their representatives with complete written instructions containing all of the required elements of preoperative instructions prior to the surgical procedure in ten of ten medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9 and MR10).

Findings include:

A review on March 03, 2022, of facility policy "Universal Protocol" dated April 9, 2021, revealed "Pre-Procedure Verification. ...2. Preoperative instructions will be provided to the patient or responsible person and shall include: a. Applicable restrictions on food and drink before surgery, b. Special preparations to be made by the patient, c. An understanding that the patient may require admission to the hospital in the event of medical need." Further review revealed the policy did not include "The required proximity of the patient to the ASF (Ambulatory Surgical Facility) for a specific time following surgery if applicable" as required by the "Department."

A review on March 03, 2022, of MR1, admitted on October 5, 2021, for a thrombectomy procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 2022, of MR2, admitted on September 22, 2021, for an Uterine Fibroid procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 20222, of MR3, admitted on September 8, 2021, for a Right Chest Tunnel Catheter exchange procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 2022, of MR4, admitted on August 27, 2021, for a Catheter Exchange procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 2022, of MR5, admitted on July 19, 2021, for a Right Fistulagram procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 2022, of MR6, admitted on July 20, 2021, for an Thrombectomy procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 2022, of MR7, admitted on April 13, 2021, for a Fistalagram Angioplasty procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 2022, of MR8, admitted on May 03, 2021, for a Fistalagram with stent procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 2022, of MR9, admitted on November 18, 2021, for a Angioplasty procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A review on March 03, 2022, of MR10, admitted on February 14, 2022, for an Catheter Insertion procedure under monitored anesthesia care, revealed written pre-operative instructions did not include information regarding the potential for the patient to remain in the required proximity to the ASF for a specific time following surgery and did not include information that the patient may require admission to the hospital in the event of medical need as required by the "Department."

A telephone interview conducted on March 21, 2022, at 1:30 PM with EMP1, EMP2 and EMP4 confirmed the facility failed to provide patients with complete written instructions containing all of the required elements of preoperative instructions prior to a surgical procedure as required by "Department" regulations for an ambulatory surgical facility.


















Plan of Correction:

Corrective Action: The current Appointment Reminder document was revised to include all required elements of pre-op written education.

This new form was approved by the Medical Staff and during the 4/19/22 quarterly meeting.

The Front Desk Coordinators who provide the instructions were educated on the required elements and this new process on 4/25/22.

The revised form is being utilized by the Front Desk Coordinators and signed by the patient or responsible person prior to the patient's procedure.

Monitoring Activities: This element will be added to the quarterly medical record review checklist. 2% of patient records or a minimum of 10 records, whichever is greater, are monitored quarterly. Results will be reported to the Quality Committee and Governing Body. This will be reported for six (6) months through January 2023.

Responsible Party: Director of Nursing, Facility Administrator and Medical Director.

Corrective action will be completed by: 8/15/22