QA Investigation Results

Pennsylvania Department of Health
CROZER-KEYSTONE SURGERY CENTER AT HAVERFORD (A DEPARTMENT OF
Health Inspection Results
CROZER-KEYSTONE SURGERY CENTER AT HAVERFORD (A DEPARTMENT OF
Health Inspection Results For:


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Initial Comments:
This report is the result of a State licensure survey conducted on November 15, 2018, at Crozer-Keystone Surgery Center At Haverford. 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:




567.1 Principle LICENSURE
CHAPTER 567 - ENVIRONMENTAL SERVICES

Name - Component - 00
567.1 Principle

The ASF shall have a sanitary environment, properly constructed,
equipped and maintained to protect surgical patients and ASF personnel from
cross-infection and to protect the health and safety of patients.


Observations:

Based on observation and interview with staff (EMP), it was determined that the facility failed to provide a safe and sanitary environment in various areas of the Operating Room (OR)Suite.

Findings include:

1. Observation on November 15, 2018, at 9:30 AM with EMP1 of OR 3 revealed a wooden Operating (OR) door with extensive areas of chipped wood and rusted hinges. Observation of the equipment in OR3 revealed rust on the wheels of the mayo stand, kick bucket and two intravenous poles. Further observation revealed the walls of OR 3 were marred and an ophthalmology surgical chair with rust on the wheels of the chair and at the base of the surgical chair.

2. Observation on November 15, 2018, at 9:55 AM with EMP1 of the Substerile Room between OR3 and OR4 revealed a wall vent covered with dust and grime, a drainage floor pipe with thick green colored residue, the floor of the room area covered with dirt and grime and thick high dust on top of autoclave #3. Further observation revealed discolored ceiling tiles and unlabeled and undated containers of cleaning chemicals in use by EMP4 for reprocessing of surgical instruments at the time of the on-site survey.

3. Observation on November 15, 2018, at 10:15 AM with EMP1 of the Sterile Processing Room revealed trash, dirt and grime on the floor behind the sterilizers, and green colored residue at the sink area, ceiling tiles not leveled and damaged and debris from the damaged ceiling tiles falling into the sterile processing room.

4. Observation on November 15, 2018, at 10:25 AM with EMP1 of OR 4 revealed a wooden OR door with extensive areas of chipped wood.

5. Observation on November 15, 2018, at 10:35 AM with EMP1 of the Decontamination Room revealed a one gallon container of enzymatic solution with a use by date of March 2016. Further observation revealed the container was opened on May 16, 2014. Further observation revealed a ultrasonic cleaner unit with a connecting probe placed in a container of enzymatic solution with no date on the enzymatic solution in the container.

An interview conducted on November 15, 2018, at 11:00 AM with EMP1 and EMP3 confirmed that the wooden doors to OR3 and OR4 was chipped and marred and the hinges door hinges contained rust. Further interview confirmed the above findings to the areas identified in the Substerile Room between OR3 and OR4, the Sterile Processing Room and the Decontamination Room. At the time of the on-site survey the facility was unable to provide a policy that required the facility to maintain a safe and sanitary environment.

















Plan of Correction:

The Administrator of the Surgery Center will ensure that the following corrective actions are taken:

1. All Operating Room doors will be replaced or repaired and will not have any chipped wood or rusted hinges. All rust on the wheels of the mayo stands, kick buckets, intravenous poles, beds, and surgical chairs will be cleaned, repaired, or replaced. All operating room walls will also be repaired and will be free of any damage. All corrective actions will be completed by February 22, 2019. The Director of Facilities is ultimately responsible for this plan of correction.

2. The wall vent in the Substerile Room between OR 3 and OR 4 will be cleaned of dust and grime. The drainage floor pipe will be cleaned to remove the green colored residue. The floor in the Substerile Room will be cleaned and the ceiling tiles will be replaced where discolored. All corrective actions will be completed by February 22, 2019. The Director of Facilities is ultimately responsible for this plan of correction.

The tops of autoclaves will be cleaned by the Environmental Services staff at the Surgery Center. All cleaning chemicals used for cleaning of surgical instruments will be labeled with the contents and expiration date. All corrective actions will be completed by February 22, 2019. The Administrator of the Surgery Center ultimately responsible for this plan of correction.


3. The floors and sink will be cleaned by the Environmental Services staff at the surgery center. All corrective actions will be completed by February 22, 2019. The Administrator of the Surgery Center ultimately responsible for this plan of correction.

The ceiling tiles will be leveled and any debris will be cleaned. All corrective actions will be completed by February 22, 2019. The Director of Facilities is ultimately responsible for this plan of correction.

4. The Director of Facilities will ensure that all Operating Room doors are replaced or repaired and do not have any chipped wood or rusted hinges. All corrective actions will be completed by February 22, 2019. The Director of Facilities is ultimately responsible for this plan of correction.

5. The Administrator of the Surgery Center will provide re-education to Sterile Processing Staff on the requirement to label all solutions with their expiration date. Education of all Sterile Processing staff will be completed by January 18, 2019. A log will also be created to document monthly checks of the enzymatic solutions by the Sterile Processing Staff. The log will be housed in the SPD room. The log will be implemented by January 18, 2019. This audit will be ongoing. The Administrator of the Surgery Center ultimately responsible for this plan of correction.

To ensure compliance with this corrective action, the Administrator of the Surgery Center or designee will conduct environmental tours of the entire Operating Room suite once per week using the Environment of Care Rounding checklist. All identified environmental issues will be shared with the individuals responsible for corrective actions and communication of the deficiencies will be documented by the Administrator of the Surgery Center or designee. Rounds by the Administrator of the Surgery Center or designee will be ongoing.

The Administrator of the Surgery Center will report the weekly audits of the environmental rounding results to the Accreditation & Regulatory Department, The Medical Director of the Surgery Center as well as the Assistant Vice President of Ambulatory Services on a monthly basis. Results will also be reported to the Ambulatory Services Patient safety and Quality Committee quarterly.

The Administrator of the Surgery Center is ultimately responsible for his plan of correction and will address any areas of non-compliance.

Additionally, a multidisciplinary rounding team will conduct environment of care tours of the Surgery Center once every six months. Rounding results will be documented by the Accreditation & Regulatory Department and results will be shared with the Administrator of the Surgery Center and the individuals responsible for corrective actions. All follow up to the identified deficiencies will be documented using rounding software.

The facility has a policy that speaks to the requirement to provide a safe and sanitary environment. Policy ID 3-3 "Cleaning of the OR Suite" speaks to the proper cleaning protocols of the entire OR Suite and the recommended practices for environmental responsibly of the Surgery Center. The policy also speaks to ensuring that a safe, clean environment is re-established at the end of each shift. The Administrator of the Surgery Center or designee will provide education on policy ID 3-3 "Cleaning of the OR Suite" to all nursing staff. The re-education of this policy will be completed by 1/18/2019. The Administrator of the Surgery Center ultimately responsible for this plan of correction.