Initial Comments:
This report is the result of a full State Licensure survey initiated on March 27,2025 and concluded on March 27,2025, at Azura Surgery 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 (8)(i) LICENSURE
Governing Body Responsibilities
Name - Component - 00
553.3 Governing Body responsibilities include:
(8) Establishing personnel policies and practices which adequately support
sound patient care to include, the following:
(i) Require the employment of personnel with qualifications commensurate with a job's responsibilities and authority, including appropriate licensure and certification.
Observations:
Based on a review of facility documents, personnel files (PF) and interview with staff (EMP1), it was determined the facility failed to ensure the staff met the qualifications and experience commensurate with the requirements listed in the job description for facility administrator for one of four personnel files reviewed (PF1).
Findings include:
Review on March 27, 2025, of facility document "Governing Body Bylaws American Access Care of SP,LLC d/b/a Azura Vascular Care South Philadelphia" last reviewed on November 19, 2024, revealed "...The Governing Body shall assume full responsibility for determining, implementing and monitoring policies governing the Center's total operation ..."
Review on March 27, 2025, of PF1 "Job Description ...Manager Facility" dated and signed by (PF1) July 29,2024, revealed "...Education: Graduate of an accredited School of Nursing(RN) or Radiology Technician with current license within the applicable state..." Further review of PF1 revealed education did not meet requirements in the facility Administrator job description.
Interview on March 27, 2025, with EMP1 and EMP2 at 2:15 PM confirmed EMP1 did not meet the written requirements for the position of facility administrator.
Plan of Correction:For a time period of 3 months all job descriptions will be verified by the Director of Nursing in addition to the Facility Administrator to make sure that the job description aligns with the policies. This monitoring will be reported to the Governing Body and QAPI quarterly for those 3 months and addressed in the quarterly meeting.
The Governing Body will review job description contents to evaluate for correct information periodically throughout the year. The policy will updated to reflect that.
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