Each medical facility shall have readily available equipment and drugs necessary for resuscitation. If local anesthesia is utilized to perform an abortion in a medical facility during the first trimester, then the following equipment shall be ready to use for resuscitative purposes:
(i) Suction Source
(ii) Oxygen Source
(iii) Assorted size oral airways and endotracheal tubes
(iv) Laryngoscope
(v) Bag and mask and bag and endotracheal tube attachments for assisted ventilation
(vi) Intravenous fluids including blood volume expanders
(vii) Intravenous catheters and cut-down instrument tray
(viii) Emergency drugs for shock and metabolic imbalance
(ix) An individual to monitor respiratory rate, blood pressure and heart rate.
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Observations:
Based on observation and interview with staff (EMP), it was determined that Planned Parenthood - York failed to have all required equipment available for resuscitative services.
Findings include:
A tour of the facility on March 19, 2025, at 10:00 AM revealed that the facility did not have the required cut-down instrument tray.
Interview with EMP1 on March 19, 2025, at 10:30 AM confirmed that the facility administers local anesthesia for procedures and did not have the required cut-down instrument tray.
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Based on observation, review of facility policy, and interview with staff (EMP), it was determined that Planned Parenthood Keystone - York failed to complete Automated External Defibrillator (AED) checks to ensure the equpment was operating properly.
A review of facility policy "Automated External Defibrillator (AED)" with a most recent review date of June 1, 2023, states "... The AED will be checked for operability on a weekly basis in accordance with the manufacturer's instructions. Checks will be recorded on the MED-306F Weekly Check of AED Log ..."
A review of the facility's "Weekly Check of AED Log" revealed that a check of the AED was completed only on January 10, 2025, February 4, 2025, and February 25, 2025.
Interview with EMP1 on March 19, 2025, at 10:00 AM confirmed that the facility failed to complete weekly AED checks.
| | Plan of Correction - To be completed: 05/08/2025
To address the deficiency, a training took place for the Center Manager on 4.10.2025 that reviewed both the AED log and the emergency supply policy.
The following corrections have either been made or will be completed by the dates noted:
1. Cutdown tray was ordered and expected to arrive on 4/22/2025
2. Weekly management oversight over completing AED checks started on 4/11/2025 and will continue indefinitely as a part of the Manager's role
Oversight:
The RQM Manager will review the log monthly for the next 90 days to ensure this requirement is being met. 4/30/2025 will be the first check and will occur at the end of each calendar month until the end of June.
Additionally, the RQM Manager will ensure the arrival of the kit by visual inspection to ensure it is in the center after it arrives. This is to be completed no later than 5/1/2025
Any non-compliance to this corrective action plan will be reported to the Senior Director of RQM for remediation
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