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:


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Initial Comments:

This report is the result of an Annual Registration survey conducted on October 24-25, 2017, 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 October 24-25, 2017, 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:




553.3 (1) LICENSURE
Governing Body Responsibilities

Name - Component - 00
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.


Observations:

Ppsp Surgical Locust Street Health Center was not in compliance with the following State Law related to Act 13 of 2002, Medical Care Availability and Reduction of Error(MCARE) Act 40 PS. Patient Safety Committee.

"Section 310. Patient safety committee. (a) Composition.-- (2) An ambulatory surgical facility's ... patient safety committee ... shall meet at least monthly."

This is not met as evidenced by:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to have an ambulatory surgical facility specific Patient Safety Committee.

Findings include:

Review on October 24, 2017, of the facility's "Patient Safety Plan ... Planned Parenthood Southeastern Pennsylvania ... Address: 1144 Locust St. ... ", dated April 2015, revealed this plan included " ... Patient Safety Committee ... 4 Health Center Managers ... ".

Review on October 24, 2017, of the "Patient Safety Committee Meeting" minutes, dated January 2017, February 2017, May 2017, and August 2017, revealed there were committee members from other Planned Parenthood Southeastern Pennsylvania affiliates attending these meetings and information from these other affiliates were included in these meeting minutes. These minutes were not specific only to the Ppsp Surgical Locust Street Health Center.

Interview with EMP1 on October 24, 2017, at 2:00 PM, confirmed the patient safety committee meetings take place with other Planned Parenthood affiliates including Far Northeast, West Chester, and Norristown. EMP1 confirmed the meetings and minutes are not specific to the ambulatory surgery center.

















Plan of Correction:

An approved Plan of Correction is not on file.


553.3 (5)(i)(ii) LICENSURE
Governing Body Responsibilities

Name - Component - 00
Governing Body responsibilities include:
(5) Adopting bylaws or similar rules and regulations for the orderly development and management of the ASF, which:
(i) Describe the authority delegated to the person in charge and to the medical staff.
(ii) Require the governing body to review and approve the bylaws, or similar rules and regulations, of the medical staff.

Observations:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to adopt governing body bylaws that were applicable to the surgery center, that described the authority to the person in charge and to the medical staff, and that required the governing body to review and approve the bylaws of the medical staff.

Findings include:

Review on October 24, 2017, of "Planned Parenthood Southeastern Pennsylvania By-laws, no date, revealed these bylaws did not address the surgery center. Further review of these bylaws revealed they did not described the authority delegated to the person in charge and to the medical staff. These bylaws also did not require the governing body to review and approve the bylaws of the medical staff.

Interview with EMP1 on October 24, 2017, at 2:25 PM, confirmed the bylaws were not dated and they did not address the surgery center.









Plan of Correction:

An approved Plan of Correction is not on file.


555.3 (f) LICENSURE
Requirements

Name - Component - 00
555.3 Requirements for membership and privileges.

(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 facility document, credential files (CF), and interview with staff (EMP), it was determined the facility failed to request and consider reports from the National Practitioner Data Bank for three of six credential files reviewed (CF4, CF5 and CF6).

Findings include:

Review on October 25, 2017, of facility document, "PPSP Credentialing requirements for contracted nurse anesthetists" dated October 25, 2017, (date of survey conducted) revealed no provision to request and consider reports from the National Practitioner Data Bank on each practitioner who requests privileges.

Review on October 24, 2017, of facility CF4 revealed the employee is a Certified Registered Nurse Anesthetist (CRNA). Further review revealed no documented evidence of a National Practitioner Data Bank report.

Review on October 24, 2017, of facility CF5 revealed the employee is a CRNA. Further review revealed no documented evidence of a National Practitioner Data Bank report.

Review on October 24, 2017, of facility CF6 revealed the employee is a CRNA. Further review revealed no documented evidence of a National Practitioner Data Bank report.

Interview on October 25, 2017, with EMP1 at approximately 11:50AM confirmed no documented evidence of a National Practitioner Data Bank report for CF4, CF5 and CF6.









Plan of Correction:

An approved Plan of Correction is not on file.


555.33 (c)(1-3) LICENSURE
Anesthesia Policies and Procedures

Name - Component - 00
555.3 Anesthesia policies and procedures

(c) Policies and procedures shall be developed or anesthesia services and shall include the following:
(1) Education, training and supervision of personnel.
(2) Responsibilities of non physician anesthetists.
(3) Responsibilities of supervising physicians or dentists.

Observations:

Based on review of facility documents, review of credential files (CF) and interview with staff (EMP), it was determined the facility failed to ensure policies and procedures were developed for the supervision of Certified Registered Nurse Anesthetists (CRNA) and failed to ensure privileges were approved for the supervision of CRNAs in two of two credential files reviewed (CF1, CF2).

Findings include:

Review on October 25, 2017, of the facility document "Anesthesia Policies," reviewed September 27, 2017, revealed no documentation that anesthesia policy and procedures addressing the supervision of the CRNA's clinical activities were developed and approved.

Review on October 25, 2017, of facility document "Job Description ... Physician-Surgical Provider ... " revealed no specific duties for supervision of the CRNA.

Review on October 24, 2017, of CF1, CF2 revealed no documentation that each of the physician-surgical providers were privileged for supervision of the CRNA.

Interview with EMP1 on October 25, 2017, at approximately 12:30 PM confirmed there were no policy and procedures addressing supervision of CRNA. EMP1 also confirmed the Job Description for the Physician-Surgical Provider did not contain specific duties for the supervision of the CRNA and the credential files for CF1 and CF2 did not contain specific privileges to supervise the CRNA.












Plan of Correction:

An approved Plan of Correction is not on file.


557.4 (a)(1-4) LICENSURE
Quality Assurance & Improvement Committee

Name - Component - 00
557.4 Quality Assurance & Improvement Committee

(a) The committee shall consist of the following:
(1) A practitioner who is not an owner,
(2) A representative of administration,
(3) A registered nurse,
(4) Other health care personnel, as appropriate.


Observations:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure the committee members included the Locust Street Center Manager or the Assistant Center Manager or other staff as assigned according to the Risk and Quality Management Plan.


Findings include:

Review on October 24, 2017 of facility document "Planned Parenthood Southeastern Pennsylvania Risk and Quality Management Fiscal Year 2017 Program Overview and Work Plan (July 1, 2016 - June 30, 2017) revealed " ... The FY17 [Fiscal Year 2017] Committee members include: ... A Center Manager or Assistant Center Manager ... Other staff as assigned based upon agenda items and/or program review".

Review on October 24, 2017 of facility's "Risk & Quality Management Meeting" minutes dated September 2016, December 2016, December 2016, February 2017, May 2017 and July 2017 revealed the Locust Street Center Manager, the Assistant Center Manager or other assigned facility staff did not attend any of these meetings.

Interview with EMP1 on October 25, 2017, at 12:30 PM confirmed the Locust Street Center Manager, the Assistant Center Manager or any other Locust Street facility staff did not attend the Risk & Quality Management Meetings.






Plan of Correction:

An approved Plan of Correction is not on file.


559.2 (2) LICENSURE
Director of Nursing

Name - Component - 00
559.2 Director of Nursing

The director of nursing shall be currently licensed as a registered nurse in this Commonwealth
and be responsible and accountable to the person in charge of the ASF for:
(2) Development and maintenance of nursing service goals and objectives,
standards of nursing practice, nursing policy and procedure manuals and written job descriptions for each
level of personnel.


Observations:

Based on review of facility document and interview with staff it was determined the facility failed to ensure Nursing Policies and Procedures were established for the facility.
Findings include:
Review on October 25, 2017, of facility document, "Job Description - Position: Director of Clinical Services ..." revealed "Primary Function/Purpose: Provides clinical leadership and oversight of PPSP family planning and abortion services ... Ensures that all clinical policies, procedures and activities are conducted in accordance with internal and external requirements ... Lead implementation of changes to the Policy and Procedure Manual and disseminate to staff with required explanations and/or training ... Oversees training and evaluation of clinical staff ... Knowledge, Skills and Abilities: Clinical - Significant experience providing direct family planning patient care and developing and overseeing clinical policies and procedures. Clinician Management - Ability to develop and implement orientation and training of clinicians, and work one-on-one and with teams to ensure compliance with policies, procedures and productivity standards ..."
A request was made to EMP1 at 10:44AM on October 25, 2017, for a policy regarding Nursing Policies and Procedures. None was provided.
Interview on October 25, 2017, at 10:44AM with EMP1, confirmed there is no policy regarding Nursing Policies and Procedures.






Plan of Correction:

An approved Plan of Correction is not on file.


Initial Comments:

This report is the result of a full State Licensure survey conducted on October 24-25, 2017, at Ppsp Surgical Locust Street Health Center. It was determined the facility was in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: