QA Investigation Results

Pennsylvania Department of Health
ASSOCIATES SURGERY CENTERS, L.L.C.
Health Inspection Results
ASSOCIATES SURGERY CENTERS, L.L.C.
Health Inspection Results For:


There are  26 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 full Medicare recertification survey conducted on August 29, 2022, August 30, 2022, and September 1, 2022, at Associates Surgery Centers. It was determined the facility was in substantial compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions for Coverage for Ambulatory Surgical Centers.

It was also determined the facility was in compliance with 42 CFR, Title 42, Part 416 - Conditions for Coverage for Ambulatory Surgical Centers at 416.51(c)(1)-(3)(i)-(x) COVID-19 Vaccination of Facility Staff.









Plan of Correction:




416.41(a) STANDARD
CONTRACT SERVICES

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When services are provided through a contract with an outside resource, the ASC must assure that these services are provided in a safe and effective manner.

Observations:

Based on a review of facility documents and interview (EMP), it was determined that the facility's governing body failed to evaluate one of 15 contracts with an outside resource to assure that services were provided in a safe and effective manner.

Findings:
On 8/29/2022, the Master Services Agreement dated 05/01/2009, was reviewed.

A review of the governing body minutes from 01/14/2021, and 01/26/2022, reveals that the Master Services Agreement was not included in the governing body's annual evaluation of contracted services.

On 8/30/2022 at 10:50am, EMP1 and EMP2 confirmed that the Master Services Agreement was not reviewed during the governing body's annual evaluation of contract services.










Plan of Correction:

The Master Services Agreement was reviewed by the Governing Body on 09/15/2022. The list of contracts to be reviewed was also updated to include the Master Services Agreement (MSA). The MSA was also sent to corporate legal counsel for review in relation to the change in ownership of Associates in Ophthalmology (AIO) and to provide any new agreement necessary within the next 60 days. These actions were documented in the GB Minutes of 09/15/2022 which will be emailed to the surveyor by the Administrator.


416.45(a) STANDARD
MEMBERSHIP AND CLINICAL PRIVILEGES

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Members of the medical staff must be legally and professionally qualified for the positions to which they are appointed and for the performance of privileges granted. The ASC grants privileges in accordance with recommendations from qualified medical personnel.


Observations:

Based on a review of facility documents, personnel files (PF), and credential files (CF), and employee interviews (EMP), it was determined that the facility failed to assure that a collaborative practice agreement was on file with the PA Department of State for certified registered nurse practitioner (CRNP).


Findings include:


A review of PF3 revealed that on 2/28/202, a collaborative agreement was signed which outlined the roles and responsibilities of the CRNP in the facility. The outlined responsibilities revealed, "Care services provided by the nurse practitioner will include preoperative assessment and orderings labs and any other appropriate testing. Preoperative education will also be provided by the nurse practitioner."


A review of CF1 revealed no collaborative practice agreement noted on the PA MD license. Further review on 8/29/2022, of the MD license on the Department of State primary source verification website on revealed the physician had no active letters on file.


A review of PF3, on 8/29/2022, revealed that a CRNP job description included, "1. Functions independently to perform age-appropriate history and physical for peri-operative patients and 2. Performs pre-operative assessments for surgical patients."



On 8/29/2022, a review of Medical Staff Bylaws and Medical Staff Rules and Regulations dated 01/26/2022, revealed, "Article V: Allied Health Professionals Section 1: Description Allied Health Professionals, other than licensed physicians, who exercise independent judgement within the areas of their professional competence and who are qualified to render care under the supervision and direction of a physician who has been accorded privileges to provide such care in the Center. If the ASF assigns patient care responsibilities to Physician Assistants and Nurse Practitioners, the medical staff shall have policies and procedures approved by the governing body, for overseeing and evaluating their clinical activities."



On 8/29/2022, a review of all medical staff credentialed by the facility's governing body revealed that the CRNP was not credentialed. On 8/29/2022 at 1:30pm, EMP2 indicated that the facility believed they did not have to credential the CRNP because the CRNP was an employee.





















Plan of Correction:

The facility filed an Application for Prescriptive Authority, Collaborative Agreement for Prescriptive Authority, and payment of application fees with the PA State Board of Nursing on 06/05/2020. A copy of the FedEx tracking document showing proof of receipt will be emailed to the surveyor by the Administrator. It was the understanding of the facility this completed the requirements to appropriately address the CRNP's role in the facility. After speaking with the surveyors on 08/29/2022, the CRNP, Renee Barrett, was contacted to complete the process of submitting her application through the state board. Mrs. Barrett submitted her application successfully on 09/21/2022. A receipt of submission will be emailed to the surveyor. Once the application is approved by the State Board of Nursing, the Clinical Director will follow-up with the State Board of Medicine to ensure Dr. Cibik's medical license is updated to reflect the collaborative practice agreement is noted on her license. The Clinical Director will also process the credentialing for the CRNP through the ASC Governing Body as appropriate once the collaborative agreement is approved by the state board within the next 60 days.


Initial Comments:


This report is the result of a State licensure survey conducted on August 29, 2022, August 30, 2022, and September 1, 2022, at Associates Surgery Centers. 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:




553.31 (a) LICENSURE
Administrative responsibilities

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A full time person in charge shall be appointed who has authority and responsibility for the operation of the ASF at all times. Qualifications, authority, responsibilities and duties of the person in charge shall be defined in a written statement adopted by the governing body.


Observations:

Based on a review of facility documents, and staff interview (EMP) it was determined that the governing body failed to appoint and delineate the qualifications, authority, responsibilities and duties of the person in charge.

Findings include:
1.A review of the members of the facility governing body on 8/29/2022 (Approved: 1/26/2022) includes (2) ex-officio members, Regional VP, Administrator, and the Clinical Director.
2.On 8/29/2022, " The Bylaws of the Governing Body of Associates Surgery Centers " (Revised: 9/28/2020; Last Approved: 01/26/2022) , Article VII- Clinical Director, " The authority and responsibility of the Clinical Director shall include ... "
3.The Bylaws of the Governing Body of Associates Surgery Centers (Revised: 9/28/2020; Last Approved: 01/26/2022) do not include a delineation of qualifications, authority, responsibilities, and duties for the administrator.
4.On 8/29/2022, a review of the organizational chart (Last Revised: 01/19/2019) reveals that the Clinical Director reports to the administrator. In addition, on 8/29/2022, a review of the clinical director ' s 2021 performance appraisal demonstrates that the appraisal was completed by the practice manager.
5.On 8/29/2022, a review of the job description (Not Dated/Signed 11/01/2006) for the clinical director was completed. " To properly execute these duties, the Director will manage and supervise all clinical aspects of Associates Surgery Center, including planning, direction, public relations, budget and finance, personnel, purchase and supply, plant maintenance, housekeeping, general administrative services and coordination of Medical Staff Activities. Specifically, the duties will include but not be limited to: ... "
6.On 8/29/2022, a review of the job description (Not Signed/Not Dated) for the administrator was completed. " Job Summary: The Administrator reports directly to the Governing Body or, if so designated, the Medical Director of Associates Surgery Centers. The Administrator will manage, supervise, and/or delegate all administrative aspects of Associates Surgery Centers including planning and direction, public relations, budget and fiancpersonnel, purchase and supply, plant maintenance, housekeeping, general administrative services and coordination of Medical Staff activities. Specifically, the duties will include but not be limited to: ... "
7.On 8/29/2022, at 2:00pm, EMP2 confirmed that the governing body bylaws did not address the role of the administrator.
8.On 8/30/2022, at 9:15am and again, at 11:00am, the job description of the Regional Vice President was requested. The job description was not received.
9.On 8/30/2022 at 10:55am, EMP2 stated that EMP2 functions as the full time administrator and acknowledged that the governing body bylaws do not delineate the authority and responsibilities of the administrator role.











Plan of Correction:

The Governing Body (GB) met on 09/15/2022 and reviewed the Management and Administration of Operations, Section 553.31 Administrative Responsibilities and the findings of the surveyor. The GB reviewed the position description of the Regional VP of Operations and found the role to be in compliance with the requirement to have an administrator with authority and responsibility for the operations of the center. The GB approved the recommended revisions of the By-Laws to reflect the Administrator's role and duties, as well as the revised duties of the Clinical Director. The GB Minutes, revised By-Laws, and position description for the Regional VP will be emailed to the surveyor by the Administrator.


555.4 (c) LICENSURE
Clinical Activities And Duties

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555.4 Clinical Activities and Duties of Physician Assistants and Certified Registered Nurse Practitioners

(c) Physician assistants and nurse practitioners shall be licensed or certified as applicable.

Observations:

Based on a review of facility documents, personnel files (PF), and credential files (CF), and employee interviews (EMP), it was determined that the facility failed to assure that a collaborative practice agreement was on file with the PA Department of State for certified registered nurse practitioner (CRNP).


Findings include:


A review of PF3 revealed that on 2/28/202, a collaborative agreement was signed which outlined the roles and responsibilities of the CRNP in the facility. The outlined responsibilities revealed, "Care services provided by the nurse practitioner will include preoperative assessment and orderings labs and any other appropriate testing. Preoperative education will also be provided by the nurse practitioner."


A review of CF1 revealed no collaborative practice agreement noted on the PA MD license. Further review on 8/29/2022, of the MD license on the Department of State primary source verification website on revealed the physician had no active letters on file.


A review of PF3, on 8/29/2022, revealed that a CRNP job description included, "1. Functions independently to perform age-appropriate history and physical for peri-operative patients and 2. Performs pre-operative assessments for surgical patients."



On 8/29/2022, a review of Medical Staff Bylaws and Medical Staff Rules and Regulations dated 01/26/2022, revealed, "Article V: Allied Health Professionals Section 1: Description Allied Health Professionals, other than licensed physicians, who exercise independent judgement within the areas of their professional competence and who are qualified to render care under the supervision and direction of a physician who has been accorded privileges to provide such care in the Center. If the ASF assigns patient care responsibilities to Physician Assistants and Nurse Practitioners, the medical staff shall have policies and procedures approved by the governing body, for overseeing and evaluating their clinical activities."



On 8/29/2022, a review of all medical staff credentialed by the facility's governing body revealed that the CRNP was not credentialed. On 8/29/2022 at 1:30pm, EMP2 indicated that the facility believed they did not have to credential the CRNP because the CRNP was an employee.





Plan of Correction:


The facility filed an Application for Prescriptive Authority, Collaborative Agreement for Prescriptive Authority, and payment of application fees with the PA State Board of Nursing on 06/05/2020. A copy of the FedEx tracking document showing proof of receipt will be emailed to the surveyor by the Administrator. It was the understanding of the facility this completed the requirements to appropriately address the CRNP's role in the facility. After speaking with the surveyors on 08/29/2022, the CRNP, Renee Barrett, was contacted to complete the process of submitting her application through the state board. Mrs. Barrett submitted her application successfully on 09/21/2022. A receipt of submission will be emailed to the surveyor. Once the application is approved by the State Board of Nursing, the Clinical Director will follow-up with the State Board of Medicine to ensure Dr. Cibik's medical license is updated to reflect the collaborative practice agreement is noted on her license. The Clinical Director will also process the credentialing for the CRNP through the ASC Governing Body as appropriate once the collaborative agreement is approved by the state board within the next 60 days.