QA Investigation Results

Pennsylvania Department of Health
CARLISLE ENDOSCOPY CENTER, LTD.
Health Inspection Results
CARLISLE ENDOSCOPY CENTER, LTD.
Health Inspection Results For:


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Initial Comments:

This report is the result of a State licensure survey conducted on December 27, 2018, at Carlisle Endoscopy 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:

Based on review of facility policies and procedures, review of personnel files (PF), and interview with staff (EMP), it was determined the facility failed to conform to all State laws.

The facility was found to be non-compliant with the following State law:

Adult Protective Services Act - Enactment Act of October 7, 2010, P.L. 484. No. 70 An Act Providing for protection of abused, neglected, exploited or abandoned adults; establishing a uniform Statewide reporting and investigative system for suspected abuse, neglect, exploitation or abandonment of adults; providing for protective services; and prescribing penalties. Chapter 5 Reporting Suspected Abuse by Employees Section 501. Reporting by employees: "(a) Mandatory reporting to agency. (1) An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse or neglect shall immediately make an oral report to an agency. If applicable, the agency shall advise the employee or administrator of additional reporting requirements that may pertain under subsection (b)".

Based on review of facility policies, it was determined the facility failed develop a policy that addressed Act 70 requirements.

Findings include:

A request was made to EMP1 on December 27, 2018, for an Act 70 policy. None was provided.

Interview with EMP1 on December 27, 2018, at 1:42 PM, confirmed the facility did not have a policy that addressed Act 70 of 2010. Further interview revealed that the facility used a book titled "Abuse and Neglect in Healthcare Facilities Guidebook, copyright 2006" in lieu of a policy for Act 70.










Plan of Correction:

Carlisle Endoscopy Center will correct deficiency #033A which relates to Governing Body response to include, conforming to an applicable Federal, State, and Local laws and having in place a policy that addresses Act 70 requirements.
Carlisle Endoscopy Center will develop a policy which addresses the Act 70 requirements that requires employees or administrator of a facility who has reasonable cause to suspect that a recipient is a victim of abuse, neglect, exploitation, or abandonment to make an immediate report.
Carlisle Endoscopy Center will complete this policy with specific instructions and reporting mechanisms in place by March 1, 2019. Carlisle Endoscopy Center will continue to provide education, related to Act 70, to staff upon hire and yearly.


557.3 (a) LICENSURE
QA & Improvement Program

Name - Component - 00
557.3 The Quality Assurance and Improvement Program

(a) The quality assurance program shall include monitoring and evaluation of data collected, based on defined criteria that reflect current knowledge and clinical experience and relate to the care provided by the service. Sources of data include the medical records, incident reports, infection control records and patient complaints. The medial record shall contain sufficient data to support the diagnosis and determine that the procedures are appropriate to the diagnosis. Facilities that treat pediatric patients shall segregate data regarding such patients.

Observations:


Based on review of facility policies and procedures, facility documents, and interview with staff (EMP), it was determined that the facility's Quality Assurance and Improvement Committee failed to ensure the ongoing monitoring was completed.

Findings include:

Review on December 28, 2018, of the "Quality Management and Improvement", Developed 20purpose of this program is to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care and resolve identified problems... "

Review on December 27, 2018, of the "Quality Management compliance with Universal Precautions" revealed a check list dated 9-30-18 and signed by a physician. However, the check list was not completed. The check list had a list of questions with an area to check either yes or no. The areas were not marked either yes or no.

Review on December 27, 2018, of the "Medication Area Quarterly Checks" revealed a check list dated 9-30-18 and signed by a physician. However, the check list was not completed. The check list had a list of questions with an area to check either yes or no. The areas were not marked either yes or no.

Review on December 27, 2018, of the "Quality Management Environmental and Safety Audit Direct Observation" revealed a check list dated 9-30-18 and signed by a physician. However, the check list was not completed. The check list had a list of questions with an area to check either yes or no. The areas were not marked either yes or no.

Interview on December 27, 2018, at 10:15 AM, with EMP 1 confirmed that the sheets were not completed even though they were signed and dated three (3) months ago.























Plan of Correction:

Carlisle Endoscopy Center will correct deficiency 573A which relates to the Quality Assurance and Improvement Program and ongoing monitoring of universal precautions compliance, medication area checks, and environmental & safety audit that are completed by the Medical Director quarterly.
Carlisle Endoscopy Center will ensure this does not occur again by having the Assistant Nurse Manager co-sign the reports that the universal precaution compliance, medication area checks, environmental/safety audit, and forms are completed by the Medical Director quarterly. The Nurse Manager will monitor the report to ensure the above corrective action is maintained per policy. This corrective action will take place immediately.