QA Investigation Results

Pennsylvania Department of Health
CHILDREN'S DENTAL SURGERY OF PHILADELPHIA
Health Inspection Results
CHILDREN'S DENTAL SURGERY OF PHILADELPHIA
Health Inspection Results For:


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Initial Comments:

This report is the result of a State licensure survey conducted on December 6, 2021, at Children's Dental Surgery Of 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:




553.3 (8)(ii) 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:
(ii) Applications for positions requiring a licensed person shall be hired only after obtaining verification of their licenses, records of education, and written references.



Observations:
Based on a review of facility policy, personnel file (PF) and interview with staff (EMP), it was determined the facility failed to verify professional licensure and education prior to hiring licensed personnel as required by the "Department" for two of two personnel files reviewed (PF3 and PF5).

Findings include:

A review of facility policy "Personnel" last revised February 3, 2021, revealed "Policy: ...4. Positions Requiring a License: Applicants for positions requiring a licensed person shall be hired only after obtaining verification of their licenses, records of education and written or [sic] references."

A review on December 6, 2021, of PF3, a registered nurse, revealed PF3 was hired August 30, 2021. Further review revealed verification of professional licensure was not completed until September 8, 2021. Further review revealed no evidence of documentation that records of education for PF3 was verified prior to hire.

A review on December 6, 2021, of PF5, a registered nurse, revealed PF5 was hired September 27, 2021. Further review revealed verification of professional licensure was not completed until September 27, 2021. Further review revealed no evidence of documentation that records of education for PF5 was verified prior to hire.

An interview conducted on December 6, 2021, at 1:29 PM with EMP1 and EMP2 confirmed verification of professional licensure and record of education for PF3 and PF5 was not completed prior to hire. EMP2 stated "We do not verify licensure before hire, we only verify (that information) before they start patient care. We are not verifying education. That information is on their resume."






















Plan of Correction:

- The Children's Surgery Center of Philadelphia will prevent future violation of Philadelphia Surgery Center Policy 311 section 4: Applicants for positions requiring a licensed person shall be hired only after obtaining verification of their licenses, records of education and references. To accomplish compliance Children's Surgery Center of Philadelphia educated the administrator and director of nursing including an attestation document that acknowledges that each employee reviewed, fully understands and will implement license checks prior to hiring through
https://www.pals.pa.gov/#/page/search
- Children's Surgery Center of Philadelphia will also verify education of all new licensed employees including diploma/ certificate from their accredited school of which they attended.
- The Children's Surgery Center will monitor license verification practices and education that include an audit of all new hires. Results of the audit will be filled out on a audit document that will be retained by the administrator that will be available upon request.
- Re-education of Administrator and Director of Nursing regarding new hire practices and review of policy 311 was completed along with a signed attestation sheet acknowledging receipt of review of policy 311.
- Audits of all new hires will be completed upon start date and presented to the Medical Advisory Board at their quarterly meetings.
- It will be the responsibility of the Administrator to verify all licensures and education; then, quarterly the administrator will submit the results of the audit to the Medical Advisory Board.



555.3. (a-f) LICENSURE
Requirements for membership & privileges a-f

Name - Component - 00
555.3. Requirements for membership and privileges.
(a) To receive favorable recommendation for appointment, or reappointment,
members of the medical staff shall always act in a manner consistent with the
highest ethical standards and levels of professional competence.
(b) Privileges granted shall reflect the results of peer review or utilization
review programs, or both, specific to ambulatory surgery.
(c) Privileges granted shall be commensurate with an individual ' s qualifications,
experience and present capabilities.
(d) 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) A 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.
(e) Reappraisal and reappointment shall be required of every member of the
medical staff at regular intervals no longer than every 2 years.
(f) The governing body shall request and consider reports from the National
Practitioner Data Bank on each practitioner who requests privileges.

Observations:

Based on review of the facility's medical staff Bylaws, credential files (CF), medical records (MR), and interview with staff (EMP), it was determined the governing body failed to ensure the medical staff was granted privileges before providing anesthesia care at the facility for four of four medical records reviewed (MR10, MR11, MR12 and MR13).

Findings include:

A review of facility document "Bylaws of the MEDICAL STAFF of CHILDREN's
SURGERY CENTERS" last revised January 22, 2021, revealed "PREAMBLE ...The Members of the Medical Staff practicing at the Center hereby organize themselves in conformity with these Bylaws. It is the intent of the Governing Body to develop and adhere to the Bylaws and Rules and Regulations in a manner consistent with Pennsylvania laws and regulations governing ambulatory surgical facilities. ...ARTICLE IV MEDICAL STAFF APPOINTMENT AND REAPPOINTMENT 1. Nature of Medical Staff Appointment. ...No practitioner shall provide health care services to or in connection with patients in the Center unless he/she is a member of the medical staff or has been granted temporary privileges in accordance with these Bylaws."

A review on December 20, 2021, of a letter from the Governing Body dated January 8, 2021, granted temporary clinical privileges through July 8, 2021, for CF7, an anesthesiologist. Further review revealed a letter from the Governing Body dated July 20, 2021, granted temporary clinical privileges through January 20, 2022. There was no evidence of documentation that CF7 had been granted privileges to practice at the facility July 9, 2021, through July 19, 2021.

A review of MR10, a 5 year old female admitted July 15, 2021, for an oral rehabilitation procedure under general anesthesia revealed CF7 was the anesthesia provider.

A review of MR11, a 5 year old male admitted July 15, 2021, for an oral rehabilitation procedure under general anesthesia revealed CF7 was the anesthesia provider.

A review of MR12, a 4 year old female admitted July 15, 2021, for an oral rehabilitation procedure under general anesthesia revealed CF7 was the anesthesia provider.

A review of MR13, a 4 year old male admitted July 15, 2021, for an oral rehabilitation procedure under general anesthesia revealed CF7 was the anesthesia provider.

A telephone interview conducted on December 20, 2021, at 11:52 AM with EMP1 confirmed the clinical privileges of CF7 had lapsed on July 9, 2021, and CF7 was not privileged to provide anesthesia care at the facility until July 20, 2021. EMP1 further confirmed CF7 had provided anesthesia care for surgical procedures performed on July 15, 2021, for MR10, MR11, MR12 and MR13.

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Plan of Correction:

- Children's Surgery Center of Philadelphia failed to provide supporting documentation that providers were granted renewed privileges at the end of the providers temporary privilege term.
- To prevent non-compliance the Children's Surgery Center of Philadelphia will track all provider temporary and permanent privilege terms by including a beginning date and expiration date of all provider privileges at the medical advisory board meetings that are held quarterly. In addition to the inclusion of the privilege terms being added to the MAB agenda the Medical Director, Administrator and Director of Nursing were re-educated on the surgery center bylaws and Surgery Center policy 503 Credentialing on 3/14/2022. Next, an attestation sheet acknowledging review of policy 503 and the procedure for requesting and approving privileges were included. Finally, an audit form was created that will be submitted and reviewed by the board annually.
- The Philadelphia Surgery Center audit form will include a review of the credentialing requirements and all provider privileges with specific focus of beginning and expiration of privilege terms.
- It will be the responsibility of the Administrator and Medical Director to maintain an audit log of all provider privilege terms; then, annually the administrator and medical director will submit the results of their audit to the GOV Board for review.