QA Investigation Results

Pennsylvania Department of Health
ABINGTON SURGICAL CENTER, LP
Health Inspection Results
ABINGTON SURGICAL CENTER, LP
Health Inspection Results For:


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Initial Comments:


This report is the result of an unannounced revisit survey conducted on November 21, 2018, following a full state licensure survey completed on April 23, 2018, at Abington Surgical 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:




565.1 Laboratory - Principle LICENSURE
CHAPTER 565 - LABORATORY & RADIOLOGY

Name - Component - 00
565.1 Principle

The ASF shall have procedures for obtaining routine and emergency
laboratory services to meet the needs of patients.


Observations:


Based on review of facility policy, facility documents and interview with staff (EMP), it was determined that the facility failed to follow their plan of correction related to survey conducted on April 23, 2018, by failing to follow their policy for conducting Cidex OPA test strip quality controls, by failing to provide documented evidence of staff education related to the "Policy on Use of Cidex OPA" and by failing to provide documented evidence that the Infection Preventionist was conducting weekly checks to ensure the "Policy on the Use of Cidex OPA" was being followed by staff.

Findings include:

Review on November 21, 2018, of facility policy, "Use of Cidex OPA," dated May 2018, revealed, " ... Central processing personnel will be educated on the testing of Cidex ... 12. As part of Infection Control processes, these checks will be monitored by the Infection Preventionist weekly to determine process is being completed ... Quality Control Procedure on Test strips ... 6. The test strips should be tested when a new bottle of Cidex OPA test strips are opened and then on a regular basis. This would be on a weekly basis when used using the test strips for the Medivators unit ... ."

Review on November 21, 2018, of facility's, "CIDEX OPA Solution Log Sheet," no date, revealed, "Date Test Strip Bottle First Opened 2-18-18, Do Not Use After 8-18-18, Bottle Lot #: 03177... ." Further revealed no quality control testing was conducted for CIDEX OPA Test Strips. Further revealed test strips were used on the following dates after the do not use date: "8-20-18," "8-21-18," 8-22-18," "8-23-18," "8-24-18," "8-27-18," "9-10-18," "9-11-18," "9-12-18," "9-13-18," "9-14-18," "9-17-18," "9-18-18," "9-19-18," "9-22-18," "9-23-18," "9-28-18," "10-01-18," "10-02-18," "10-03-18," and "10-04-18."

Review on November 21, 2018, of facility's, "CIDEX OPA Solution Log Sheet," no date, revealed, " Date Test Strip Bottle First Opened 10-18, Do Not Use After 4-18, Bottle Lot #: 032247... ." Further revealed these dates are inaccurate as the noted do not use date comes before the noted date the test strip bottle was first opened. Further revealed no quality control testing was conducted for CIDEX OPA Test Strips. Further revealed, these test strips were used between 10-5 and 10-18 and on 11-20 and 11-21.

Request was made on November 21, 2018 to EMP2 for documented evidence that the Infection Preventionist was conducting weekly checks to ensure the "Policy on the Use of Cidex OPA" was being followed by staff. None provided.

Request was made on November 21, 2018 to EMP2 for documented evidence of staff education related to the "Policy on Use of Cidex OPA." None provided.

Interview with EMP1 and EMP2 on November 21, 2018 at 11:00 AM confirmed quality control testing for Cidex OPA test strips were not being done as per respective policy and manufacturer guidelines. Further confirmed facility failed to provide documented evidence of staff education related to the Policy on Use of Cidex OPA. Further confirmed facility failed to provide documented evidence that the Infection Preventionist was conducting weekly checks to ensure the "Policy on the Use of Cidex OPA" was being followed by staff.







Plan of Correction:

The Abington Surgical Center's policy on Use of Cidex OPA is included in a new policy and procedure book specifically designed for the Central Processing staff to review and understand. This policy and procedure book will be reviewed and understood by the central processing staff and evidence provided of such will be included as a sign-off sheet in the binder.

After the policy is reviewed with the central processing staff, they will be responsible for documenting the testing of Cidex OPA on the Cidex OPA Solution Log Sheet. The Infection Prevention staff, under the supervision of the Director of Nursing, will be responsible to monitor the policy being followed as written on a weekly basis. The Infection Prevention staff will document weekly on a log sheet that these tests are being properly preformed. If the tests are not being done properly the Infection Prevention staff will report the issue immediately to either the Director of Nursing or the Executive Director.

The Director of Nursing or designee will audit the log sheets to ensure compliance. The Director of Nursing or designee will audit the log sheets monthly for six months if no deficiencies are reported.

The Infection control committee and the Performance Improvement committee will review this Plan of Correction. Once in effect compliance with this plan of correction will be reported to and documented by these committees.

The Governing Body will be made aware of this deficiency at the next regularly scheduled Board meeting in March 2019 and will review and approve the plan of correction. This will be documented in the meeting agenda and minutes.



567.3 (b)(3) LICENSURE
Policies and Procedures

Name - Component - 00
567.3 Policies and procedures

(b) Current written policies and procedures to assure definite and
valid infection control shall include,but not be limited to, the
following:
(3) Sterilization and disinfection, including suitable equipment for routine and rapid sterilization.

Observations:


Based on review of facility policy, facility documents and interview with staff (EMP), it was determined that the facility failed to follow their plan of correction related to survey conducted on April 23, 2018, by failing to follow their policy for conducting weekly TOSI [Test Object Surgical Instruments] testing of washer/disinfector, by failing to provide documented evidence of staff education related to the policy "TOSI testing of washer/disinfector" and by failing to provide documented evidence that the Infection Preventionist was conducting weekly checks to ensure the policy "TOSI testing of washer/disinfector" was being followed by staff.

Findings include:

Review on November 21, 2018, of facility's policy, "TOSI testing of washer/disinfector," dated 5/18, revealed, "Policy: It is the policy of the ... to perform appropriate TOSI testing on the washer disinfector to monitor the effectiveness of the lumen cleaning process. Testing is done on a weekly basis to ensure the instrument washer is cleaning properly ... Log of TOSI results: All results of TOSI testing are kept in a log book in the Central Processing area ... The results of TOSI testing will be monitored by the Infection Preventionist to determine policy is being followed correctly."

Review on November 21, 2018, of facility's "Automated Washer Disinfector Test Log Sheet," revealed, weekly testing not completed on the following dates: "8-27-18," "9-3-18," "9-10-18," "11-5-18," "11-12-18," and "11-19-18."

Request was made on November 21, 2018, to EMP2 for documented evidence that the Infection Preventionist was conducting weekly checks to ensure the TOSI testing was being performed accurately. Provided "Central Processing Weekly Checks."

Review on November 21, 2018, of facility's, "Central Processing Weekly Checks," revealed checks were not completed for the following dates: "9-4-18," "9-10-18," "10-22-18," "10-29-18," "11-5-18," "11-12-18," and "11-19-18."

Request was made on November 21, 2018 to EMP2 for documented evidence of staff education related to TOSI testing. None provided.

Interview with EMP1 and EMP2 on November 21, 2018 at 11:00 AM confirmed TOSI testing on washer disinfector was not performed on above dates. Further confirmed Infection Preventionist weekly checks to ensure TOSI testing was being performed accurately was not conducted on the above dates. Further confirmed no documented evidence of staff education related to TOSI testing.










Plan of Correction:

The Abington Surgical Center's policy on conducting weekly TOSI (Test Objects Surgical Instruments) testing of washer/disinfector is included in a new policy and procedure book specifically designed for the Central Processing staff to review and understand. This policy and procedure book will be reviewed and understood by the central processing staff and evidence provided of such will be included as a sign-off sheet in the binder.

After the policy is reviewed with the central processing staff, they will be responsible for documenting the TOSI testing on the Central Processing Weekly Checklist. The Infection Prevention staff, under the supervision of the Director of Nursing, will be responsible to monitor the policy being followed as written on a weekly basis. The Infection Prevention staff will document weekly on a log sheet that these tests are being properly preformed. If the tests are not being done properly the Infection Prevention staff will report the issue immediately to either the Director of Nursing or the Executive Director.

The Director of Nursing or designee will audit the log sheets to ensure compliance. The Director of Nursing or designee will audit the log sheets monthly for six months if no deficiencies are reported.

The Infection control committee and the Performance Improvement committee will review this Plan of Correction. Once in effect compliance with this plan of correction will be reported to and documented by these committees.

The Governing Body will be made aware of this deficiency at the next regularly scheduled Board meeting in March 2019 and will review and approve the plan of correction. This will be documented in the meeting agenda and minutes.