Initial Comments:
This report is the result of an Annual Registration survey initiated off-site on February 13, 2025, and completed on-site on March 13, 2025, at Philadelphia Women's Center, Inc. It was determined the facility was in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.
Plan of Correction:
Initial Comments:
This report is the result of a full State Licensure survey initiated off-site on February 13, 2025, and completed on-site on March 13, 2025, at Philadelphia Women's Center, Inc. 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:
567.3 (b)(2) LICENSURE
Policies and Procedures
Name - Component - 00
567.3 Policies and procedures
(b) Current written policies and procedures to assure definite and
valid infection control shall include,but not be limited to, the
following:
(2) Surgical asepsis
Observations:
Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a staff members beverage container was not stored in an area where there is a risk of exposure to blood or body fluids.
Findings include:
A request was made of EMP1 and EMP2 for a facility policy, procedure, guideline or protocol staff follow regarding safe storage of personal beverage containers or not storing personal beverage containers in the sterilization room. EMP1 and EMP2 revealed there is no written policy.
Observation on March 13, 2025, of the facility's Sterilization room revealed a staff members beverage container stored next to the sterilizer.
EMP2 revealed there is a risk of exposure to blood or body fluids in the sterilization room and personal beverage containers are not to be stored in this room. EMP2 confirmed there is a risk of splashing and potential contamination of the personal beverage container.
Cross reference
567.1 Principle
Plan of Correction:1. This deficiency will be corrected as it relates to the individual by the Administrator providing all Full time, part time, and per diem Medical assistants training on the risks of having personal beverages stored in the sterilization room. The administrator will also have all Full time, part time, and per diem Medical assistants sign a document confirming training and committing to keeping personal beverages in the sterilization room.
2. To ensure that this problem does not occur, the Administrator, or appointed manager will complete weekly random checks for a period of two months to ensure that staff do not have personal beverages. Any finding will be documented and kept for review.
3. To ensure that this solution is sustained. The Administrator will add this to the 2026 QI plan as an in-service for all staff at the start of the year.
4. This corrective action will be completed by 04.27.2025
567.3 (b)(4) LICENSURE
Policies and Procedures
Name - Component - 00
567.3 Policies and procedures
(b) Current written policies and procedures to assure definite and
valid infection control shall include,but not be limited to, the
following:
(4) Sterilized materials are packaged, labeled and dated in a consistent manner.
Observations:
Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure reusable laryngoscopes were stored in a manner to prevent contamination in the crash cart and the evacuation bag.
Findings include:
A request was made of EMP1 and EMP2 for a facility policy, procedure, guideline or protocol staff would follow to ensure laryngoscopes were stored in a manner to prevent contamination. None was provided.
Observation on March 13, 2025, revealed a reusable laryngoscope (a lighted instrument used to examine the interior of the larynx through the mouth and to place a breathing tube into the windpipe) stored in the facility's crash cart. The package used to store the laryngoscope was torn.
Observation on March 13, 2025, revealed a reusable laryngoscope stored in the facility's evacuation bag. The package used to store the laryngoscope was torn and there was tape securing the package shut.
Interview with EMP2 confirmed the above findings at the time of the observations. EMP2 revealed the laryngoscope is considered a sterile instrument.
Plan of Correction:1. This deficiency will be corrected as it relates to the individual, The administrator will purchase disposable laryngoscopes and blades.
2. To Ensure that the problem does not occur, the Director of Nursing will add checking the laryngoscopes and blades a part of the monthly crash cart and evacuation back checks.
3. To ensure that this solution is sustained, the Director of Nursing will report any deficiencies noted to the Administrator for corrective actions.
4. This corrective action will be completed by 04.27.2025
567.32 LICENSURE
Policies and Procedures
Name - Component - 00
567.32 Policies and procedures
Procedures shall be developed for cleaning and care of equipment, for
establishment of cleaning schedules, for cleaning methods and for proper
use of cleaning supplies and disposal of waste. Suitable equipment shall be
provided to facilitate cleaning.
Observations:
Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a medication refrigerator / freezer was free of ice buildup and the facility failed to ensure the Biohazard refrigerator / freezer used to store products of conception was free of ice buildup.
Findings include:
A request was made of EMP1 and EMP2 for a facility policy, procedure, guideline or protocol staff would follow to ensure refrigerator / freezers were free of ice buildup. None was provided.
1. Observation on March 13, 2025, of the facility's medication refrigerator revealed ice buildup in the freezer measuring approximately 1 inch thick in the front of the freezer to approximately 4 inches thick in the back of the freezer.
Further observation of the medication refrigerator on March 13, 2025, revealed the following medications:
Rhogam (a medication given to pregnant women whose blood is negative for Rhesus factor (Rh) protein but are carrying an Rh-positive fetus)
Ativan (a medication used to treat anxiety)
Rocuronium ( a medication used to relax muscles prior to surgery)
Methylergonovine (a medication to treat excessive bleeding)
Flu vaccinations
Hepatitis vaccinations
Tuberculosis skin tests
Interview with EMP2 confirmed the above findings at the time of the observations. EMP2 revealed the facility does not have a form to track when these refrigerator / freezers were last cleaned or defrosted.
2. Observation on March 13, 2025, of the facility's Biohazard refrigerator / freezer used to store products of conception revealed ice buildup on the top and side measuring approximately 1 inch thick.
Interview with EMP2 confirmed the above findings at the time of the observations. EMP2 revealed the facility does not have a form to track when these refrigerator / freezers were last cleaned or defrosted.
Plan of Correction:1. This deficiency will be corrected by the Administrator and Director of Nursing thawing out the medication refrigerators/freezers and the biohazard refrigerator/freezer.
2. To Ensure that the problem does not occur, the Administrator will add thawing of the medication and biohazard refrigerators/freezers a part of the monthly deep clean for both respective areas.
3. To ensure that the solution is sustained, the administrator or designee will supervise and sign off on the monthly deep cleans for a period of three months.
4. This corrective action will be completed by 04/27/2025
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