QA Investigation Results

Pennsylvania Department of Health
DREXEL CENTERS FOR DIGESTIVE HEALTH
Health Inspection Results
DREXEL CENTERS FOR DIGESTIVE HEALTH
Health Inspection Results For:


There are  21 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 a full State Licensure survey conducted on November 28, 2018 at the Drexel Center for Digestive Health. It was determined that 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 documents and interview with staff (EMP), it was determined the facility failed to conform to all applicable State laws.

Drexel Centers for Digestive Health was not in compliance with the following State law:

"Act 52 of 2007, Medical Care Availability and Reduction of Error (MCARE) Act Chapter 4. Health Care-Associated Infections 40 P.S.1303.403. Infection control plan (a) Development and Compliance. - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include: (1) A multidisciplinary committee of the following if applicable to that specific health facility: ... (iii.) Pathology ... (vi.) Physical Plant personnel ... ".

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 all the required members of the infection control committee (Pathology, Plant Operations Personnel).

Findings include:

Review on November 28, 2018, of the facility's "Infection Control Plan," dated revised February 14, 2018, revealed, "IV. Organizational responsibility for compliance of the Center for Digestive Health Infection Control Plan is the Center for Digestive Health Quality Committee. B. The Quality Committee is multidisciplinary and includes, but is not limited to ... Pathology representative ... Facilities Management ... ".

Review on November 28, 2018, facility documents "Infection Control Committee" meeting minutes, dated May 23, 2018, and August 22, 2018, revealed no documentation of attendance by a Pathology or Facilities Management representative.

Interview with EMP2 on November 28, 2018, at 3:00 PM confirmed there was no documentation of attendance at these meetings by a representative from Pathology or a Facilities Management Representative.

_____________


Based on review of facility documents and interviews with staff (EMP), it was determined the facility's Patient Safety Program failed to conform to all applicable State laws.

Drexel Centers for Digestive Health was not in compliance with the following State law:

The Medical Care Availability and Reduction of Error Act, Act 13 of 2002, Chapter 3, Section 309 Patient Safety Officer
A patient safety officer of a medical facility shall do all of he following:

(1) Serve on the patient safety committee.
(2) Ensure the investigation of all reports of serious events and incidents.
(3) Take such action as is immediately necessary to ensure patient safety as a result of an investigation.
(4) Report to the patient safety committee regarding an action taken to promote patient safety as a result of investigations commenced pursuant to this section.

This is not met as evidenced by:

Based on review of facility document and interviews with staff (EMP), it was determined the facility's Patient Safety Program contained specific duties of the Patient Safety Officer.

Findings include:

Review on November 28, 2018, of facility document, "Patient Safety/Risk Management Program," dated revised October 31, 2018, revealed it did not contain specific duties of the Patient Safety Officer.

Interview with EMP2 on November 28, 2018, at 12:15 PM confirmed the facility's "Patient Safety/Risk Management Program" did not contain specific duties of the Patient Safety Officer.
























Plan of Correction:


Administrator and DON will ensure that representation from Plant Operation and Pathology are invited and in attendance to the Infection Control Committee meeting. These invites will be sent for the December ICC meeting and all ICC meetings in the future. Committee members have been identified and invitations have been sent for December ICC meetings and future meetings. This will be completed by 12/31/18.




The Administrator and DON will modify Quality Assurance Patient Safety Policy to include the duties of the patient safety officer. The patient safety officer will ensure that there is a process for all incidents to be reported and fully investigated. Interventions will be designed and implemented to protect patient safety.
All investigations and actions will be reported at the patient safety committee. The policy to be brought to the Governing Body meeting in December 2018. These duties will be included in the policy by 1/14/19




553.3 (3) LICENSURE
Governing Body Responsibilities

Name - Component - 00
553.3
Governing Body responsibilities include:
(3) Assuring the facilities and personnel are adequate and appropriate to carry out the goals and objectives.


Observations:

Based on review of facility documents, personnel files (PF), and staff interview (EMP), it was determined that the facility failed to ensure personnel files were completed for four of four personnel files. (PF1, PF2, PF3 and PF4).

Findings include:

Review on November 28, 2018, of facility policy "Employee Health Records Policy," effective date February 14, 2018, revealed "... Applies to all Endoscopy Center Staff: 1. All staff employee records kept on hard copy or electronically will be governed by this policy. 2. Information in employee personnel files are to include: a. pre-employment documents, including, job applications or resumes, offer letters, code of conduct and other key policies and emergency notification forms ..."

Review on November 28, 2018, of facility policy "Staff Health Status Requirements, ' revised August 10, 2016, revealed "... applies to all Endoscopy Center Staff ... b. All employees are tested at least annually for TB ..."

Interview on November 28, 2018, with EMP2 confirmed the PF1, PF2, PF3, PF4 do not contain the required documents and testing.






Plan of Correction:

Clinical Operations Director will complete staff personnel files on the Administrator and DON and report them to the Governing Body. Staff records will be completed by 1/14/19. Administrator and DON will the have ongoing responsibility of their current and new staff members' files. Completed staff files will be reported to the Governing Body.

Administrator and DON will customarily review new staff files with the Governing Body.

Administrator and DON will complete CFDH staff files which include pre-employment documents; job application, resumes, offer letters, code of conduct and other key policies and emergency notification forms. Clinical Operations Director will complete personnel files on the Administrator and DON to include; pre-employment documents; job application, resumes, offer letters, code of conduct and other key policies and emergency notification forms. Staff records will be completed by 1/14/19.



Administrator and DON will schedule CFDH staff for annual one step PPD tests. System of annual notification will be put in place by Administrator and DON. Documentation will be kept on site in staff files. This action plan will be reported to the Governing Body. Staff records will be completed by 1/14/19.

Administrator and DON will establish a file check list for all newly hired employees to assure that records are complete before signing off on orientation. To be completed by 1/14/19.



553.3 (13)(i-iv) LICENSURE
Govern Body Responsibilities

Name - Component - 00
Governing Body responsibilities include:
(13) Approving major contracts or arrangements affecting the medical care provided under its auspices, including, those concerning;
(i) The employment for contractual arrangements with practitioners and others providing direct patient care.
(ii) The provision of all treatment related services including, radiology, medical laboratory, pathology , anesthesia and pharmaceutical services.
(iii) The provision of care by other health care organizations.
(iv) The provision of education to students and post graduate trainees.



Observations:

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to obtain written contracts or written service agreements for services provided at the surgery center.

Findings include:

Review on November 28, 2018, of the Governing Body bylaws "Drexel University Meeting of the Board of Trustees, May 7, 2017" revealed "A. The Governing Body's Responsibilities shall include: ... (m) In accordance with Drexel University's policies and procedures, and the CFDH's (Center For Digestive Health) budget, approving major contracts or arrangements affecting the medical care provided under its auspices, including those concerning: ... (i) The employment or contractual arrangements with practioner's and others providing direct patient care; (b) The providing of all treatment related services including radiology, medical laboratory, pathology, anesthesia and pharmaceutical services; (iii) The provision of care by other health care organizations ..."

Interview on November 29, 2018, at 3:00 PM with EMP1 revealed the following services were provided by a third party for the Center for Digestive Health: patient transfer agreement with an acute care facility, laboratory services, pathology services, medical staff, anesthesia, nursing services, human resources, industrial hygienist and Infection Preventionist, occupational health, staff education services, pest control services, waste, trash and medical waste disposal, building maintenance, mechanical services, ventilation and HVAC services, electrical safety and medical gas

Interview on November 28, 2018, at 3:15 PM with EMP1 confirmed the facility did not have a written contract or written service agreement for the above provided services.

_____________

Based on interview with staff (EMP1), it was determined the facility failed to ensure quality review was conducted on services provided at the surgery center through contracts or written service agreements.

Findings include:

On November 28, 2018, surveyor requested documentation of quality review performed on services provided by contract and written services agreements provided at the surgery center. None was provided.

Interview with EMP1 and EMP2 on November 28, 2018, at approximately 3:00 PM confirmed the facility did not conduct a quality review on services provided by contract or written services agreements at the facility.






Plan of Correction:

Administrator, DON and Director of Clinical Operations will work with legal department to develop service agreements or addendum to current agreements to include patient transfer agreement with an acute care facility, laboratory services, pathology services, medical staff, anesthesia, nursing services, human resources, industrial hygienist and Infection Preventionist, occupational health, staff education services, pest control services, waste, trash and medical waste disposal, building maintenance, mechanical services, ventilation and HVAC services, electrical safety and medical gas. Service Agreement plan will be submitted to the Governing Body by 1/14/19.


Administrator and DON will ensure that an annual quality review will be conducted on written service agreements. Quality review of written service agreements will be done by the Governing Body. Annual quality review plan will be in place by 1/14/19.



553.4 (f) LICENSURE
Other Functions

Name - Component - 00
553.4 OTHER FUNCTIONS

(f) The governing body shall ensure that personnel are provided with
continuing education which is relevant to their responsibilities within the
organization.


Observations:

Based on review of facility documents and interview with staff (EMP) it was determined the Governing Body failed to ensure personnel were provided continuing education which was relevant to their responsibilities for four of four personnel files (PF) reviewed. (PF1, PF2, PF3 and PF4)


Review on November 28, 2018, of the Governing Body Bylaws "Drexel University Meeting of the Board of Trustees, May 7, 2017" revealed "Establishment of a Drexel Center for Digestive Health Committee with Governing Body Powers ... A. The Governing Body's Responsibilities shall include: ... 4. Other functions ... (f) The Governing Body shall ensure that personnel are provided with continuing education which is relevant to their responsibilities and CFDH (Center for Digestive Health).


Review on November 28, 2018, of facility policy "Staff Education," revised October 4, 2016, revealed "Purpose: to ensure all Endoscopy attend both required and elective in-services ... Applies to all endoscopy staff. 1. Education: Required and elective in-services ... All physician and nursing employees must complete the annual Life Safety Review ... i. Life Safety review includes Infection Control, Fire Safety, Electrical safety, Radiation Safety, Hazard communication and back safety ..."


Review on November 28, 2018, of PF1, PF2, PF3, and PF4 revealed no documentation for current mandatory training.







Plan of Correction:

Administrator and DON will complete CFDH staff personnel files to include; life safety, infection control, fire safety, electrical safety, radiation safety, hazard communication and back safety. An annual education checklist will be created by Administrator and DON to ensure training and education is completed on a timely basis and checklist will be completed by 1/14/19. Administrator and DON will be responsible for their respective staff education and training. Documentation of training will be reported to the Governing Body.

Administrator and DON will have the ongoing responsibility of ensuring education is complete for their respective staff.

Staff records will be updated and completed by 1/14/19.


Clinical Director of Operations will include all mandatory training certificates in Administrator and DON personnel file. Staff records will be completed by 1/14/19.



553.31 (a) LICENSURE
Administrative responsibilities

Name - Component - 00
A full time person in charge shall be appointed who has authority and responsibility for the operation of the ASF at all times. Qualifications, authority, responsibilities and duties of the person in charge shall be defined in a written statement adopted by the governing body.


Observations:

Based on review of facility documents, personnel files (PF), and interview with staff (EMP), it was determined the facility failed to ensure the facility Administrator was hired with qualifications commensurate with the job's responsibilities and authority.

Findings include:

Review on November 28, 2018, of the facilities Governing Body bylaws "Drexel University Meeting of the Board of Trustees, May 7, 2014" revealed " Resolution: Establishment of a Drexel Center for Digestive Health (CFDH) Committee with Governing Body Powers ...A. Governing Body ...(h)(i) require employment of personnel with qualifications commensurate with a job's responsibilities and authority, including appropriate licensure and certifications ... C. Person in Charge/Medical Director, 1. The Governing Body shall appoint a full-time person in charge who has authority and responsibility for the overall operation and management of the CFDH at all times. The person in charge shall be physician licensed to practice medicine in the Commonwealth of Pennsylvania under the Medical Practice Act of 1985 ... The Person in Charge shall the authority, responsibility and duty to conduct day-to-day operations of the CFDH ..."

Review on November 28, 2018, of PF1 revealed no documentation the employee was a physician, licensed to practice medicine in the Commonwealth of Pennsylvania.

Interview on November 28, 2018, of EMP1 confirmed they were the person in charge of the day-to day operations of the facility and confirmed they were not a licensed physician.


This is a repeat deficency
November 27, 2018
Event ID Z4UV11




Plan of Correction:

Amendments will be made to the bylaws and will be reviewed and adopted by the governing body. Amendment to bylaws will be made which will indicate the administrator will oversee day-to-day operations. This change will be monitored by the Governing Body on an annual basis. The bylaws will indicate that the governing body has appointed the administrator for oversight of "day-to-day" operational responsibilities. The Director of Clinical Operations will be responsible to ensure and monitor that the Administrator is overseeing "day-today-operations." In addition, the Administrator will hold quarterly "Plan of Correction reviews" addressing compliance with all components of the corrective action plan. These quarterly review findings will be reported to the Governing Body, and on the compliance status with the corrective action plan will be discussed at all 2019 Governing Body meetings. This change will be adopted and reviewed by the Governing Body by January 14, 2019. The Governing Body will review the Medical Director's role as outlined in bylaws by 1/14/19. The Director of Clinical Operations will educate the Administrator of the job duties per job description by 1/14/2019


555.11 (a) LICENSURE
MEDICAL ORDERS - Written

Name - Component - 00
555.11 Medical orders
Written orders

(a) Medication or treatment shall be administered by authorized persons to administer drugs and medications only upon written and signed orders of a practitioner acting within the scope
of the practitioner's license.


Observations:

Based on review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure medications or treatments were administered upon written and signed orders of a practitioner in eight of eight medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8).

Findings include:

On November 28, 2018, surveyor requested policy for medication and treatment orders. None was provided.

Review on November 28, 2018, of MR1, MR2, MR3, MR4, MR5, MR6, MR7 and MR8 revealed these patients were admitted to the facility for a procedure between July 13, 2018, and November 9, 2018. Further review of the "Recovery Room Record" for MR1, MR2, MR3, MR4, MR5, MR6, MR7 and MR8 revealed documentation "Meets Discharge Criteria ... IV [intravenous] Discontinued." Continued review of MR1, MR2, MR3, MR4, MR5, MR6, MR7 and MR8 revealed no documentation of written and signed practitioner orders for the IV, including type and rate of fluid to be administered to each patient.

Interview with EMP2 on November 28, 2018, at approximately 4:00 PM confirmed the facility did not have a policy for written and signed practitioner orders for the administration of medications or treatments, including the type and rate of fluids to be administered. Further interview with EMP2 confirmed there was no documentation of written and signed practitioner orders for intravenous fluids administered, including type and rate of fluids to each of the patients in MR1, MR2, MR3, MR4, MR5, MR6, MR7 and MR8.





Plan of Correction:


Medical Director and DON will develop standing orders for IV including type and rate of fluid to be administered to each patient. Standing orders will be in place by 1/14/19.



Medical Director and DON will develop a written policy for the administration of medication and treatments, including the type and rate of fluids to be administered. The policy will be presented to the quality committee and governing body for approval by 1/14/19. Clinical and medical staff will be educated on policy in the medical staff meeting in January 2019. Medical Director and DON will put monthly chart audit in place of 10 charts per month for the first 3 months which will be reported to the quality improvement committee. Additional periods of 3 months of audits will continue if there is less than 100% compliance. DON of will be have ongoing responsibility of these chart audits.



557.2 (c)(1-8) LICENSURE
The Plan

Name - Component - 00
The plan shall emphasize the ongoing nature of the quality assurance program and the
comprehensiveness of the scope of the program which shall include monitoring and evaluation of the following:
(1) Medical staff functions including:
(i) Peer-based review of clinical performance of individuals with clinical privileges
(ii) Surgical case and tissue review.
(2) Anesthesia services
(3) Nursing services
(4) Pharmaceutical services
(5) Pathology and Radiology services
(6) Infection control procedures
(7) Procedures performed in the ASF and their necessity
(8) Reports of accidents, injuries and safety hazards


Observations:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to follow their "Quality Improvement Plan" and failed to ensure there was documentation that emphasized the ongoing nature of the Quality Assurance program included monitoring and evaluation of Medical staff functions including: peer based review of clinical performance of individuals with clinical privileges, surgical case and tissue review, anesthesia services, nursing services, pharmaceutical services, pathology services, infection control procedures and procedures performed in the ASF and their necessity.

Findings include:

Review on November 28, 2018, of facility document "Drexel University Meeting of the Board of Trustees ... Establishment of a Drexel Center for Digestive Health Committee with Governing Body Powers," dated May 7, 2014, revealed, "A. Governing Body 3. g. Assuring that the quality of care is evaluated and that identified problems are appropriately addressed ... F. Quality Assurance and Improvement Committee 2. The QAI Committee functions shall include: (a) evaluating data submitted as part of the quality assurance program, (b) reviewing credentials (c) reviewing tissue examination reports, (d) reviewing the infection control program, (e) reviewing the standards of practice in all specific areas ... ".

Review on November 28, 2018, of facility document "Quality Improvement Plan," undated, revealed, "VII. Performance Measures Monitored on an Annual Basis ... time out process ... patient satisfaction ... conscious sedation monitoring and outcomes ... endoscopy disinfection effectiveness ... documentation .. advance directives ... peer review ... documentation of colon preparation."

Review on November 28, 2018, of facility documents "Quality Committee Agenda," dated February 14, 2018, and "Quality Improvement Committee- Meeting Minutes," dated August 22, 2018, revealed no documentation of monitoring and evaluation of Medical staff functions including: peer based review of clinical performance of individuals with clinical privileges, surgical case and tissue review, anesthesia services, nursing services, pharmaceutical services, pathology services, infection control procedures and procedures performed in the ASF and their necessity. Continued review of these facility documents revealed no documentation of annual monitoring of performance measures contained in the facility's "Quality Improvement Plan."

Interview with EMP2 on November 28, 2018, at 2:00 PM confirmed there was no documentation in the "Quality Committee Agenda" or the "Quality Improvement Committee Meeting Minutes" of monitoring and evaluation of Medical staff functions including: peer based review of clinical performance of individuals with clinical privileges, surgical case and tissue review, anesthesia services, nursing services, pharmaceutical services, pathology services, infection control procedures and procedures performed in the ASF and their necessity. Further interview with EMP2 confirmed there was no documentation of annual evaluation of performance measures contained in the facility's Quality Improvement Plan.










Plan of Correction:



The Medical Director, Administrator and DON will implement a Quality Improvement Plan that will address peer-based review of clinical performance of individuals with clinical privileges, surgical case and tissue review, anesthesia services, nursing services, pharmaceutical services, pathology services, infection control procedures and procedures performed in the ASF and their necessity. The Quality Improvement Plan will be reviewed in next QI Committee meeting 12/2018 and sent to the Governing Body for approval. The Directory of Quality and Patient Safety will be a representative at both Quality Committee Meeting and Governing Body meetings. QAI policy will be in place by 12/2018.


Quality Improvement Committee will review in part- and oversee-time out process, patient satisfaction, conscious sedation monitoring and outcomes, endoscopy disinfection effectiveness, documentation, advance directives, peer review, documentation of colon preparation on an annual basis and plan in place by 1/14/19.



557.4 (b)(1-5) LICENSURE
Quality Assurance & Improvement Committee

Name - Component - 00
557.4 Quality Assurance and Improvement Committee

(b) Committee functions shall include:
(1) Evaluating data submitted as part of the quality assurance program,
(2) Reviewing credentials,
(3) Reviewing tissue examination reports,
(4) Reviewing infection control program,
(5) Reviewing the standards of practice in all specific areas of the ASF.


Observations:


Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to follow their "Quality Improvement Plan" and failed to ensure there was documentation that emphasized the ongoing nature of the Quality Assurance program included monitoring and evaluation of Medical staff functions including: peer based review of clinical performance of individuals with clinical privileges, surgical case and tissue review, anesthesia services, nursing services, pharmaceutical services, pathology services, infection control procedures and procedures performed in the ASF and their necessity.

Findings include:

Review on November 28, 2018, of facility document "Drexel University Meeting of the Board of Trustees ... Establishment of a Drexel Center for Digestive Health Committee with Governing Body Powers," dated May 7, 2014, revealed, "A. Governing Body 3. g. Assuring that the quality of care is evaluated and that identified problems are appropriately addressed ... F. Quality Assurance and Improvement Committee 2. The QAI Committee functions shall include: (a) evaluating data submitted as part of the quality assurance program, (b) reviewing credentials (c) reviewing tissue examination reports, (d) reviewing the infection control program, (e) reviewing the standards of practice in all specific areas ... ".

Review on November 28, 2018, of facility document "Quality Improvement Plan," undated, revealed, "VII. Performance Measures Monitored on an Annual Basis ... time out process ... patient satisfaction ... conscious sedation monitoring and outcomes ... endoscopy disinfection effectiveness ... documentation .. advance directives ... peer review ... documentation of colon preparation."

Review on November 28, 2018, of facility documents "Quality Committee Agenda," dated February 14, 2018, and "Quality Improvement Committee- Meeting Minutes," dated August 22, 2018, revealed no documentation of monitoring and evaluation of Medical staff functions including: peer based review of clinical performance of individuals with clinical privileges, surgical case and tissue review, anesthesia services, nursing services, pharmaceutical services, pathology services, infection control procedures and procedures performed in the ASF and their necessity. Continued review of these facility documents revealed no documentation of annual monitoring of performance measures contained in the facility's "Quality Improvement Plan."

Interview with EMP2 on November 28, 2018, at 2:00 PM confirmed there was no documentation in the "Quality Committee Agenda" or the "Quality Improvement Committee Meeting Minutes" of monitoring and evaluation of Medical staff functions including: peer based review of clinical performance of individuals with clinical privileges, surgical case and tissue review, anesthesia services, nursing services, pharmaceutical services, pathology services, infection control procedures and procedures performed in the ASF and their necessity. Further interview with EMP2 confirmed there was no documentation of annual evaluation of performance measures contained in the facility's Quality Improvement Plan.










Plan of Correction:

Under the direction of the Medical Director the Administrator and DON will ensure the following items are standing agenda items for the QIC; (1) evaluating data submitted as part of the quality assurance program, (2) reviewing credentials (3) reviewing tissue examination reports, (4) reviewing the infection control program, (5) reviewing the standards of practice in all specific areas. The next QIC Committee will take place in December 2018. The Quality Improvement Committee will report this to the Governing Body. The Directory of Quality and Patient Safety will be present at both Quality Improvement and Governing Body meetings. These standard agenda items will be in place by 1/14/19.




Under the direction of the Medical Director the Administrator and DON will ensure the annual monitoring of Medical staff functions including: peer-based review of clinical performance of individuals with clinical privileges, surgical case and tissue review, anesthesia services, nursing services, pharmaceutical services, pathology services, infection control procedures and procedures performed in the ASF and their necessity. These items will have begun a monitoring process by 1/14/19.




567.41 LICENSURE
MAINTENANCE SERVICE - Principle

Name - Component - 00
567.41 Principle

The ASF shall be equipped, operated and maintained to sustain its
safe and sanitary characteristics and to minimize health hazards in the ASF
for the protection of patients and employes.


Observations:

Based on observation and interview with staff (EMP1) it was determined the facility failed to ensure the endoscopy processing room was maintained to provide a sanitary environment.

Findings include:

Review on November 28, 2018, of facility document "Infection Control Plan," revised February 14, 2018, revealed "... VII. Assessment and Surveillance of Infections ... C. surveillance activities will be used to identify risks pertaining to patients, staff ... 2. Infection Control rounds maybe made a random intervals, at the time of policy and procedure review, during environment of care rounds ... Random audits are performed by Drexel University Office of Environmental Safety and Health ..."

On November 28, 2018, a request was made for the environment of care rounds for the facility. None provided.

Observation on November 28, 2018, at approximately 3:30 PM of the high-level disinfection processing room revealed an automated endoscope processor. Further observation revealed the flooring under the automatic processor was warped and discolored.

Interview on November 28, 2018, with EMP2 confirmed environment of care rounds are performed at the facility and confirmed the flooring of processing room used for high level disinfection was warped and discolored.






Plan of Correction:

Administrator will ensure going forward that environmental safety rounds are completed by the industrial engineer on a quarterly basis and results documented and stored in the environmental safety rounds binder. Addendum to Infection Control policy will outline that the EOC rounds will be done on a quarterly basis and reported up to the Infection Control Committee. The addendum and infection control policy will be reported to the governing body by 1/14/19. Environmental safety rounds will be reported to the Infection control committee on a quarterly basis. This will be completed by 1/14/19.

Associate Director of Clinical Practices & Facilities Operations will schedule a solution to improve the floor under the scope reprocessing unit by 1/14/19



567.43 LICENSURE
Ventilation System

Name - Component - 00
The ventilation system shall be inspected and maintained in accordance with the written maintenance schedule to ensure that a properly conditioned air supply meeting minimum filtration, humidity and temperature requirements is provided in critical areas such as the surgical and recovery suites under
Chapter 571 (relating to construction standards).


Observations:


Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to ensure the ventilator hood in the high-level disinfection room was inspected annually.
Findings include:

Review on November 28, 2018, of an email correspondence to the facility from Drexel University Department of Environmental Health and Safety revealed " The Department of Environmental Health and Safety measured the exhaust canopy hood in the scope sterilizer room on January 19, 2017 ... "

Interview on November 28, 2018, at approximately 2:00 PM with EMP3 confirmed the ventilator hood was not inspected every year. Further interview confirmed there were no other inspection reports for the ventilator hood.





Plan of Correction:

Associate Director of Clinical Practices & Facilities Operations will schedule an inspection of the exhaust canopy hood to be completed by 1/14/19. An addendum to Infection Control policy will outline that the inspection of the ventilator hood will be done on an annual basis and reported to up to the to the infection control committee and governing body. The Administrator and Associate Director of Clinical Practices will ensure that this inspection will be done on an annual basis. The addendum and infection control policy will be reported to the governing body by 1/14/19.


569.1 LICENSURE
CHAPTER 569 - FIRE & SAFETY - Principle

Name - Component - 00
569.1 Principle

The ASF shall have an organized fire, safety and disaster program
under the direction and supervision of 1 or more persons qualified to
implement the program.


Observations:

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to ensure the Fire Safety Plan included provisions to conducted quarterly safety assessments for fire equipment.

Findings include:

Review on November 28, 2018 of facility document "Fire Safety Plan" not dated, revealed no documentation for the testing of fire and safety systems, automatic fire extinguishing equipment and automatic and manual alarm testing.

Interview on November 28, 2018, with EMP3 confirmed the Fire Safety Plan does not include the above requirements.




Plan of Correction:



Director, Fire and Emergency Services will revise Fire Safety Plan to include process of facilitating quarterly drills and the inspection/audit of fire equipment. Associate Director of Clinical Practices & Facilities Operations will be responsible for scheduling the quarterly inspections/audits of the alarms, extinguishers and sprinklers. Drills and inspections will be reported to the patient safety committee. The Administrator will ensure of the completion of the quarterly drills. This plan will be in place by 1/14/19.



569.13 LICENSURE
Testing Fire Warning Systems

Name - Component - 00
569.13 Testing Fire Warning Systems

Fire safety systems, including automatic fire extinguishing systems,
automatic and manual alarms, stand pipes and hose reels shall be of an
approved type. They shall be kept in good operating condition and inspected
by qualified ASF personnel at least every 3 months. Records of the
inspections shall be kept on file for the licensure period.


Observations:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure the fire alarm system was inspected at least every 3 months.

Findings include:

A review on November 28, 2018, of facility documentation revealed inspections were not conducted every threee months at the facility to evaluate the fire safety system.

Review of facility document "Report of Sprinkler Inspection" revealed that one inspection was conducted September 19, 2018.

Interview on November 28, 2018, with EMP3 confirmed quarterly inspections are not conducted.







Plan of Correction:

Associate Director of Clinical Practices & Facilities Operations will ensure Fire Warning Systems Fire safety systems, including automatic fire extinguishing systems, automatic and manual alarms, stand pipes and hose reels shall be of an approved type. They shall be kept in good operating condition and inspected on a quarterly basis. Documentation of inspection will be kept on site and reported to the Patient Safety Committee. The administrator will add an addendum to the fire safety plan to be approved by the Governing Body that fire safety systems will be inspected every 3 months. The Administrator will ensure of the completion of system inspections. This plan will be in place by 1/14/19.


569.15 LICENSURE
Safety Education Program

Name - Component - 00
569.15 Safety Education Program

Employes shall participate in the safety program and perform the duties
delegated to them and be instructed in the operation of the fire warning
system, the proper use of fire fighting equipment and the procedure
to follow if electric power is impaired.



Observations:


Based on review of facility documents, personnel files (PF) and interview with staff (EMP) it was determined the facility failed to ensure employees were instructed in the use of the fire warning system, the proper use of fire equipment and the procedure to follow if there is a power failure.

Findings include:

A review on November 28, 2018, of facility documentation revealed no evidence that employees participated in a fire safety program

A review on November 28, 2018, of PF1, PF2, PF3 and PF4 revealed no evidence that employees participated in a fire safety program.

An interview conducted on November 28, 2018, at 3:00 PM with EMP3 confirmed that a fire safety program was not provided to employees.





Plan of Correction:

Administrator will schedule annual fire safety training through Director, Fire and Emergency Services. This will be completed by 1/14/19. The Administrator will create an addendum to the Fire Safety Plan to include the scheduling of annual fire safety training. The Fire Safety Plan will be sent and reviewed to the Governing Body. The administrator will schedule annual training and add this training to the annual staff training checklist. Fire safety training will be reported to the patient safety committee, quality committee and governing body.

The Administrator and DON will ensure Fire safety program participation by all staff and documentation of completion will be kept in staff files


569.21 (a) LICENSURE
EVACUATION - Fire Drills

Name - Component - 00
569.21 Fire Drills

(a) Fire, internal disaster and evacuation drills shall be held at
least quarterly for ASF personnel and under varied conditions.


Observations:

Based on a review of facility documentation and interview with staff (EMP), it was determined the facility failed to ensure that fire drills were conducted at least quarterly.

Findings include:

A review on November 28, 2018, of facility document "Drexel Medicine Gastroenterology Ambulatory Surgery Center," dated revealed no documentation fire drills were conducted for the second quarter.

Interview on November 28, 2018, with EMP3 confirmed the second quarter fire drill was not conducted.






Plan of Correction:

The Administrator will create an addendum to the Fire Safety Plan to include scheduling of fire drills to be done quarterly. The Fire Safety Plan will be sent and reviewed to the Governing Body by 1/14/19.


Administrator will schedule fire drills on a quarterly basis by 1/14/19.


The fire drills will be conducted by the Administrator under the guidance of the Director, Fire and Emergency Services.

The Administrator will report documentation to the Director, Fire and Emergency services for review and critique. Fire drill reports will be reported up to the patient safety committee.

The Administrator will be responsible for the overall completion of quarterly fire drills



569.34 LICENSURE
Electrical Safety

Name - Component - 00
569.34 Electrical Safety

Appliances, instruments and installations shall be tested before
use to determine compliance with grounding, current leakage and other
device safety requirements to ensure protection of patients and employees. A
program of routine maintenance shall be effectively enforced to ensure that
electrical receptacles and plugs, wires and connectors are safe. If an
appliance requiring three wire circuitry for grounding is attached to
as two wire outlet, the adaptor plug pigtail shall be attached to a
ground.


Observations:

Based on interview with staff (EMP), it was determined the facility failed to ensure there was a program of routine maintenance for the electrical receptacles, plugs, wires, and connectors.

Findings include:

On November 28, 2018, surveyor requested the routine maintenance documentation of the facility's electrical testing for electrical receptacles. No documented evidence was provided.

Interview with EMP3 on November 28, 2018, at 2:15 PM confirmed there was no documented evidence of routine maintenance for the electrical testing for electrical receptacles.














Plan of Correction:

Associate Director of Clinical Practices & Facilities Operations will submit work orders and schedule a test of the facility's electrical by receptacles by 1/14/19. The Administrator and DON will create an addendum to the patient safety program that electrical receptacles will be tested on an annual basis which will be sent to the patient safety committee for review and the GB for approval by 1/14/19

The Administrator will ensure annual testing is scheduled in the future by adding it to an annual inspection list. The will be completed by 1/14/19.