QA Investigation Results

Pennsylvania Department of Health
PPSP SURGICAL LOCUST STREET HEALTH CENTER
Health Inspection Results
PPSP SURGICAL LOCUST STREET HEALTH CENTER
Health Inspection Results For:


There are  17 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
This report is the result of an Annual Registration survey conducted on September 1, 2016, at Ppsp Surgical Locust Street Health Center. 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 conducted on September 1, 2016, at Ppsp Surgical Locust Street Health Center. 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:




551.3 LICENSURE
DEFINITIONS

Name - Component - 00
551.3 Definitions


Observations:

Based on a review of policies and procedures and medical records (MR), and interview with facility staff (EMP), it was determined this Class B Ambulatory Surgical Facility failed to document the physical status (PS) classification of patients for four of 15 medical records reviewed (MR3, MR7, MR9, and MR10).

Findings include:

State Regulation "551.3 Definitions...The following words and terms, when used in this subpart, have the following meanings, unless the context clearly indicates otherwise:...Physical status classifications-The evaluation of the patient's overall health as it would influence the conduct and outcome of anesthesia or surgery, or both. Physical status shall be defined within one of five assigned classes which are:
(i) Class 1 patients have no organic, physiologic, biochemical, metabolic or psychiatric disturbance. The operation to be performed is for a local pathologic process and has no systemic effect.
(ii) Class 2 patients have a systemic disturbance which may be of a mild to moderate degree but which is either controlled or has not changed in its severity for some time.
(iii) Class 3 patients suffer from significant systemic disturbance, although the degree to which it limits the patient's functioning or causes disability may not be quantifiable.
(iv) Class 4 patients suffer from severe systemic diseases that are already life-threatening and may or may not be correctable by surgery.
(v) Class 5 patients are moribund and not expected to survive without surgery... ."

Review on September 1, 2016, of policy "Chapter 2: Analgesia and Sedation", dated June 2014, revealed there was no provision in the policy to require a Physical Status on all patients.

Review on September 1, 2016, of MR3 revealed the patient had a procedure performed at the facility on August 6, 2016. Further review of MR3 revealed no documented evidence that a PS classification was assigned to this patient.

Review on September 1, 2016, of MR7 revealed the patient had a procedure performed at the facility on August 5, 2016. Further review of MR7 revealed no documented evidence that a PS classification was assigned to this patient.

Review on September 1, 2016, of MR9 revealed the patient had a procedure performed at the facility on July 16, 2016. Further review of MR9 revealed no documented evidence that a PS classification was assigned to this patient.

Review on September 1, 2016, of MR10 revealed the patient had a procedure performed at the facility on July 7, 2016. Further review of MR10 revealed no documented evidence that a PS classification was assigned to this patient.

Interview with EMP1 on September 1, 2016, at 1:22 PM confirmed the above patients had procedures performed at the facility and there was no documented evidence PS classifications were assigned to the patients.
























Plan of Correction:

By 10/28/16, the ASF (Surgical Locust Street Health Center, Planned Parenthood Southeastern Pennsylvania) will implement the requirement to evaluate and document the Physical Status (PS) classification for local anesthesia patients. Currently, all patients receiving IV sedation are being evaluated. Documentation of Physical Status will be added to medical record forms to ensure all patients' health will be evaluated "as it would influence the conduct and outcome of anesthesia or surgery, or both" (State regulation 551.3).

The Director of Clinical Services (with Medical Director approval) will update the ASF's policy "Chapter 2: Analgesia and Sedation" to include the requirement to require a Physical Status on all patients. The policy changes will be communicated by the ASF's Medical Director via email communication to all providers (and the ASF person-in-charge) to instruct on the requirement to include Physical Status classification in the medical evaluation of all patients including those receiving only local anesthesia. This communication will be available for Department review.

The ASF person-in-charge (Center Manager) is responsible for ensuring implementation of this requirement, training staff on appropriate documentation, and regularly monitoring medical records for documentation of PS. The Director of Clinical Services will audit of patient medical records in one month following implementation (December 2016) of this requirement and the ASF's Medical Director will ensure on-going compliance through quarterly medical record audits.

The policy changes will be presented for review and approval on 10/27/16 at the October meeting of the Board (Governing Body). The Director of Risk Quality Management and Training is responsible for the implementation of Plan of Correction and will monitor the above mentioned activities to ensure compliance.