Initial Comments:
This report is the result of a full State Licensure survey conducted on July 19, 2023, at Premier Surgical Center, with additional documentation review concluding on July 25, 2023. 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:
51.4 (c) LICENSURE
Change on Ownership/Management
Name - Component - 00
51.4. Change in ownership; change in management.
(c) A health care facility shall notify the Department in writing at least 30 days after a change of management of a health care facility. A change in management occurs when the person responsible for the day to day operation of the health care facility changes.
Observations:
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to provide notification to the Department of Health (Department) for a change in the Director of Nursing at least 30 days prior to its occurrence.
Findings include:
Review on July 21, 2023, of the license renewal application submitted by Premier Surgical Center revealed a change of management occurred during quarter four of 2022.
Review at approximately 9:00 AM on July 25, 2023, of the "Premier Surgical Center Governing Body Meeting," dated October 19, 2023, revealed PF1 was no longer full time. PF4 was now the Lead RN/Director of Nursing.
EMP1 confirmed the required notification was not sent to the Department and that there was no policy for providing notification to the Department of Health.
Plan of Correction:1. Premier Surgical Center had a policy regarding Mandatory Reporting that was created and approved on 08/19/2021 and amended on 11/17/23. The amended version did state within the policy, "the facility will notify the Department in writing within 30 days after a change of management of the facility. A change of management occurs when the person responsible for the day to day operation of the facility changes." The policy did not include all 30 day DAAC notifications prior to or after the event, DAAC 60 day notifications following certain events, the specific email address to send the changes to, or what subject lines to use when reporting these changes. This policy has been addressed and updated. All missing aspects have been added to the Mandatory Reporting to the State policy. This updated policy will be reviewed at the next Governing Body meeting for approval.
2. The Clinical Director and Lead RN will conduct a 30-day review of all current changes or future changes to be made in the facility to determine if any or all need to be reported to the DAAC. The meeting will be documented to ensure compliance with applicable regulations. The Clinical Director will cc Lead RN on the email to the DAAC to verify all changes have been submitted correctly.
3. The meeting notes and any necessary notifications will be printed out and placed in a binder. Reporting of the monthly meeting notes will be addressed, monitored, and reported quarterly to the Patient Safety Committee/ QAPI Committee and presented to Governing Body Meeting to ensure compliance.
4. If we have been notified of any changes made by the DOH, the change will be made immediately.
|