This report is the result of a State licensure survey conducted on March 22, 2019, at Afp Surgery 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:
567.1 Principle LICENSURE
CHAPTER 567 - ENVIRONMENTAL SERVICES
Name - Component - 00
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.
Based on review of facility documentation, observation and interview with staff (EMP), it was determined the facility failed to ensure the manufacturer's maintenance and certification guidelines were maintained for radiology equipment used to provide patient care services.
A tour of the facility on March 22, 2019, at 1:10 PM revealed a Mini C-Arm (radiology machine) and a Portable X-Ray machine. Further observation revealed neither the Mini C-Arm nor the Portable X-Ray machine had a current annual preventive maintenance sticker. Further review revealed no evidence of documentation of a compliance test for the Mini C-Arm.
Review on March 22, 2019, of facility documentation "FluroScan-P/N 110575" revealed " 4.1.2 Annual Inspection/Registration. ...State Diagnostics...Radiation Health and Safety Agencies will annually visit facilities to perform tests insuring...are operating properly. Others will allow independent, State Certified Physics professionals to perform compliance testing. Annual Maintenance must be performed by a [XXXX] trained service technician. Verify that all certification labels are affixed in their proper locations.
An interview conducted on March 22, 2019, at 1:50 PM with EMP1 confirmed the Mini C-Arm and Portable X-Ray machine had not received an annual preventive maintenance check by a trained service technician. Further interview confirmed the Mini-C-Arm had not received a compliance test by a certified physicist.
Plan of Correction:
A trained service technician performed a preventive maintenance evaluation on our Portable X-Ray machine on August 15th, 2018 and again on March 25th, 2019. The Center will have preventive maintenance checks done every six months per manufacturer's instructions. We will keep records of these checks at the Center and have them readily available at all times. Appropriate maintenance stickers will be affixed to the machine at all times.
The Center's Flouroscan C-Arm machine will have an annual preventive maintenance check done by a trained service technician. This annual check was performed on August 15th, 2018. A current maintenance sticker is on the machine. We will have an annual compliance test performed by a certified physicist on the Flouroscan C-Arm machine. Our Flouroscan C-Arm machine was evaluated by a physicist on March 29th, 2019. Appropriate maintenance stickers will be affixed to the machine at all times. Records of preventive maintenance will be kept at the Center and will be readily available at all times.
It will be the duty of the Director of Nursing and the Medical Director to ensure that the preventive maintenance checks are done. The preventive maintenance checks will be added to a Facilities and Environment Checklist form. The results of the maintenance checks and any maintenance required will be reported to the Patient Safety Committee. The Patient Safety Committee will review the Facilities and Environment Checklist quarterly. The Patient Safety Committee will monitor the results of the Portable X-Ray machine inspection every six months. The Patient Safety Committee will monitor the results of the Flouroscan C-Arm machine annually.
The Corrective action will be completed by June 8th, 2019.