Initial Comments:
This report is the result of a State licensure survey conducted on February 8, 2024, at Muve - West Chester Ambulatory Surgical Center, 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:
555.3 (b) LICENSURE
Requirements
Name - Component - 00
Privileges granted shall reflect the results of peer review or utilization review programs, or both, specific to ambulatory surgery.
Observations:
Based on review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to ensure peer reviews were performed on five of ten credential files reviewed (CF2, CF3, CF4, CF5 and CF10).
Findings include:
Review on February 8, 2024, of the facility's "Peer Review" policy revealed, "The Muve West Chester Ambulatory Surgical Center will conduct Peer Review on all medical staff members and the Allied Health Staff on a continuous basis. The purpose of the medical staff peer review plan is to document the process at the Surgery Center for implementing and conducting a physician and allied health, peer review monitoring and evaluation process. All clarifications of this plan will follow the Bylaws of the Medical Staff. All physicians and allied health practitioners, privileged by the organization, will be subject to peer review as outlined in this plan ..."
Review of CF2 on February 8, 2024, revealed no peer review documentation.
Review of CF3 on February 8, 2024, revealed no peer review documentation.
Review of CF4 on February 8, 2024, revealed no peer review documentation.
Review of CF5 on February 8, 2024, revealed no peer review documentation.
Review of CF10 on February 8, 2024, revealed no peer review documentation.
Interview with EMP1 on February 8, 2024, at approximately 12:00 PM confirmed the facility did not have documentation for peer reviews on CF2, CF3, CF4, CF5, and CF10.
Plan of Correction:Update current credentialing policy verbiage from all "allied health staff" to all "advanced practice practitioners" need to have a peer review completed prior to being recredentialed at Muve, West Chester.
The center has adopted Surgery Partner's CRNA and PA Peer Review forms.
The center reviewed all APP charts and had a peer review done for providers who did not receive a peer review at the time of their recredentialing.
The center will work with the credentialing company to identify what APP are up for recredentialing, the center will obtain a peer review prior to recredentialing the APP and will present this information to the Board prior to the APP being recredentialed at the center.
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