Initial Comments:
This report is the result of a State licensure survey conducted on January 29, 2024, and completed on February 22, 2024, at Penn Digestive And Liver Health Center University City. 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. (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 a review of the facility's Medical Staff Bylaws, credential files (CF), and interview with staff (EMP), it was determined the facility failed to ensure the criteria for Medial Staff Membership for privileges requested and declined by a practitioner (physician) during the credentialing process were reviewed for accuracy and approved consistent with the Medical Staff Appointment process detailed in the Medical Staff Bylaws and according to "Department" regulations for an ambulatory surgical facility for one of one credential file reviewed (CF1).
Findings include:
Review of the facility's Medical Staff Bylaws last revised July 13, 2023, revealed "Article 3-Medical Staff Membership, 3.1 Nature of Medical Staff Membership...The criteria for granting or denial of privileges shall be consistently applied by the Medical Center for each requesting Practitioner....Article 5, 5.2: Initial Appointment Process: In no instance will an application for appointment be processed or forwarded to the Credentials and Practitioner Review Committee, nor will an appointment be made or clinical privileges be awarded until the process of verification of requested information is completed....5.2-2: Verification of Accuracy of Information Requested: In no instance will an appointment be awarded until the process of verification of requested information is completed. If the verification process is incomplete more than sixty (60) days after the application was completed and submitted, the application shall be considered voluntarily withdrawn by the applicant. The applicant may reapply pursuant to Article 5.1-3 of the Medical Staff Bylaws....5.2-3: Department Chair Action: (a) The Chair of each Department in which the applicant seeks clinical privileges shall evaluate the applicant's...(b) As part of the process of performing this evaluation, the Department Chair has the right to meet with the applicant to discuss any aspect of the application, qualifications and requested clinical privileges. ...6.5 Determination of Individual Clinical Privileges: Each initial application for staff appointment by a potential Practitioner and each application for reappointment shall contain a request for specific clinical privileges. ... 6.5-1, Process of Determination: Clinical privileges shall be evaluated and determined as part of the initial appointment and reappointment processes and in accordance with the process established in Article 5 of these Bylaws. ...6.5-2, Revision of Clinical Privileges: Any Practitioner with clinical privileges may apply in writing at any time for a revision in the Practitioner clinical privileges by submitting such request to the Department Chief as appropriate or Department Chair. The review of such a request shall be processed in accordance with Article 5 of these Bylaws pertaining to review of applications for reappointment...."
Review of CF1, a gastroenterology physician, revealed an application for appointment to the facility's medical staff dated and signed by CF1 on April 21, 2023, at 12:24 PM. Further review revealed CF1 declined with a response of "NO" to the following privilege at the Penn Digestive And Liver Health Center University City (PDLH) "Gastroenterology Outpatient Privileges: Applies admission criteria to decide on the procedures to perform at PDLH for adults and adolescents ages 13-17(contingent on leadership approval) related to Gastroenterology. May evaluate, diagnose consult and provide care to patients with acute and chronic disease of the digestive system." Further review revealed CF1 was granted approval for the privilege although CF1 (physician) declined to request the privilege with a response of "No". Further review revealed CF1 was appointed to the facility's medical staff (gastroenterology) August 17, 2023, through July 31, 2025, at PDLH with the privilege declined by CF1 to deliver services to Gastroenterology Outpatients.
An interview conducted on January 29, 2024, at 1:45 PM with EMP 27 confirmed that CF1 (physician) declined the privilege "Gastroenterology Outpatient Privilege" at Penn Digestive And Liver Health Center University City (PDLH). EMP14 also confirmed CF1 (physician) had not applied for a revision to the approved delineated clinical privileges for the medical staff appointment period beginning August 17, 2023, through July 31, 2025.
An interview conducted on February 9, 2024, at 8:45AM with EMP 28 confirmed that CF1 (physician) declined the outpatient privilege "Gastroenterology Outpatient Privilege" by entering "No" in the application space provided for outpatient services rendered at PDLH.
An interview conducted on February 22, 2024, at 11:30AM with EMP 28 confirmed the facility failed to follow the medical staff appointment process detailed in the Medical Staff Bylaws for CF1 (physician).
Plan of Correction:Action Plan:
1. Following the finding, the affected medical staff applicant requested the omitted cognitive privilege to amend their original application for medical staff privileges at Penn Digestive and Liver Health on February 16, 2024, with the Department Chair approving the request on February 19, 2024. The updated privilege request was presented to the Credentials and Practitioner Review Committee for a recommendation for approval, completed on February 26, 2024. The request was presented to the Medical Executive Committee (MEC) for their recommendation for approval on February 27, 2024. It was formally presented to the Penn Presbyterian Medical Center Trustee Board Executive Committee for approval on February 29, 2024. The provider has been notified via a letter of their updated privilege following the approval process.
2. To prevent a re-occurrence, the Office of Medical Affairs (OMA) leadership created re-education for its staff on resolving discrepancies between the privileges sought and those submitted for approval by the Department Chief. The assigned OMA staff were instructed on the findings, related state regulations, and the current facility-approved Medical Staff Bylaws and Accompanying Manuals, which govern the processes for credentialing and privileging providers who practice at PDLH. This education was completed by February 21, 2024.
3. The medical staff appointment and reappointment applications and privileges for all Gastroenterologists credentialed and privileged for the PDLH facility will be reviewed to ensure the privileges requested by applicants in their initial and reappointment applications match the privileges approved and recommended by the Department Chair and the Credentials and Practitioner Review Committee, and that were then approved by the Penn Presbyterian Medical Center Trustee Board Executive Committee. Any discrepancies will be identified and corrected whereby the applicant must request the privilege that would be reviewed for approval by the PPMC Credentials and Practitioner Review Committee, Medical Executive Committee, and Trustee Board Executive Committee, with corresponding documentation to the applicant. This will be completed by March 6, 2024.
4. The OMA Manager will present the results of this licensure finding and the corresponding actions implemented to correct the finding, along with the outcomes of the focused review of privileges, to the next PDLH Quality Committee on April 19, 2024. The ASF Board of Trustees Ambulatory Surgical Facility Committee will receive the POC information with outcomes on May 14, 2024. To prevent a re-occurrence, the Office of Medical Affairs (OMA) leadership created re-education on resolving discrepancies between the privileges sought and those submitted for approval by the Department Chair. To sustain compliance, the OMA Manager or designee will conduct a concurrent review for any new providers in Fiscal Year 2024 to confirm that PDLH privileges correspond with privileges granted per regulation. The review results will be reported to the quarterly PDLH Quality Committee, with a report to the Board of Trustees Ambulatory Surgical Facility Committee through the remainder of the fiscal year.
Title of person responsible for compliance: Manager, Office of Medical Affairs
Date of Completion: April 19, 2024
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