Pennsylvania Department of Health
DIGESTIVE DISEASE INSTITUTE, INC.
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 31 surveys for this facility. Please select a date to view the survey results.

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DIGESTIVE DISEASE INSTITUTE, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a full State Licensure survey initiated on April 8, 2025, and concluded on April 10, 2025, at Digestive Disease Institute, Inc. 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:

553.3 (8)(ii) LICENSURE Governing Body Responsibilities:

553.3 Governing Body responsibilities include:
(8) Establishing personnel policies and practices which adequately support
sound patient care to include, the following:
(ii) Applications for positions requiring a licensed person shall be hired only after obtaining verification of their licenses, records of education, and written references.

Observations:

Based on review of facility documents and staff interviews (EMP), it was determined that the facility failed to ensure that written references were obtained for licensed personnel prior to beginning employment for three of 10 credentialing files (CF) reviewed (CF7, CF8, and CF9).

Findings include:

The facility was not able to provide the Department with a policy to address the requirement of written reference be obtained for licensed personnel prior to being hired.

Review of CF7 revealed no written references were obtained in the credentialing record.

Review of CF8 revealed no written references were obtained in the credentialing record.

Review of CF9 revealed no written references were obtained in the credentialing record.

On April 10, 2025, an interview with EMP1 confirmed the above documentation to be accurate.

Plan of Correction - To be completed: 04/30/2025

A written policy was modified to address the requirement of written references being obtained for licensed personnel prior to being hired. A minimum of 2 written references will be required by all licensed personnel to be provided prior to employment per policy. This will be an ongoing requirement for re-credentialing as well, ensuring that this does not occur again. This policy was reviewed by the Medical Director and will get final Board approval on 7/9/2025.

555.22 (c)(1-5) LICENSURE Surgical Services - Preoperative Care:

555.22 Pre-operative Care

(c) Written instruction for preoperative procedures, which have been approved by the medical
staff, shall be given to the patient or responsible person, and shall include:
(1) Applicable restrictions upon food and drink before surgery
(2) Special preparations to be made by the patient
(3) The required proximity of the patient to the ASF for a specific time following surgery if applicable.
(4) An understanding that the patient may require admission to the hospital in the event of medical need.
(5) The requirement that, upon discharge of a patient who has received sedation or general anesthesia, a responsible person shall be available to escort patient home. With respect to patients who receive local or regional anesthesia, a medical decision shall be made regarding whether such patients require a responsible person to escort them home.

Observations:

Based on review of policy, medical records (MR) and interviews with staff (EMP), it was determined the facility failed to ensure that written preoperative instructions were provided to patients for four of ten medical records reviewed (MR2, MR6, MR7, and MR8).

Findings include:

On April 10, 2025, a review of facility policy "Preoperative Requirements/Testing for Procedures" revealed "Preoperative Orders (if indicated) to be in patient's record."

On April 10, 2025, a review of MR2 revealed no instructions were provided to the patient prior to the procedure. The information in the chart contained the same date in which the Preoperative Orders were provided and the procedures were conducted.

On April 10, 2025, a review of MR6 revealed no instructions were provided to the patient prior to the procedure. The information in the chart contained the same date in which the Preoperative Orders were provided and the procedures were conducted.

On April 10, 2025, a review of MR7 revealed no instructions were provided to the patient prior to the procedure. The information in the chart contained the same date in which the Preoperative Orders were provided and the procedures were conducted.

On April 10, 2025, a review of MR8 revealed no instructions were provided to the patient prior to the procedure. The information in the chart contained the same date in which the Preoperative Orders were provided and the procedures were conducted.

On April 10, 2025, an interview with EMP1 confirmed the above documentation was accurate.

Plan of Correction - To be completed: 05/01/2025

The pre-procedure instructions are reviewed with the patient when the "assessment" telephone call is made. This is to ensure that the patient received instructions and that they were informed of pre-procedure preparations that would need to be performed prior to procedure date. Within this EHR document there was a newly added area for the date to be documented that the patient was given instructions and a date that they were reviewed via assessment. This will ensure that the instructions were documented and reviewed with the patient prior to the date of the procedure. This will be a required field moving forward to ensure compliance with regulations. This modification was approved by the Medical Director for immediate use.

A randomized chart audit will be conducted by the Nursing Director to ensure compliance with regulation. This audit will be done on 10 random charts for the next 3 quarters and then periodically thereafter.

567.1 LICENSURE Principle:

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 review of policy, observation, and interview with staff (EMP), it was determined that the facility failed to ensure that a safe and sanitary environment was maintained.

Findings include:

On April 10, 2025, review of facility policy "Infection Control Management Plan Overview" with a most recent revision date of 2011, revealed "Goal: Provide a safe and sanitary Environment to protect both Patients and Health Care Workers from hazards (including biological) consistent with state, federal, and CDC guidelines. The facility has approvied and implemented policies that comply with all applicable OSHA regulations for HCW's ... Identification of problems and formulation of resolutions to real potential Infection Control issues ..."

On April 10, 2025, observation tour revealed in the scope room the smaller EGD scope cabinet would not close properly and showed damage.

On April 10, 2025, an interview with EMP1 confirmed the above documentation is accurate.

Plan of Correction - To be completed: 04/30/2025

The EGD scope cabinet door is to be replaced and sanitized to ensure that the EGD scopes are stored in a safe and sanitary environment. This has been ordered and will be replaced immediately upon arrival. Until this can be repaired this cabinet will not be used for scope storage. The EGD scopes and Colon scopes will be stored in the larger cabinet to ensure a safe and sanitary environment is kept, reducing the risk of infection until this repair can be made.

567.23 LICENSURE Clean Linen:

567.23 Clean Linen

Clean linen shall be available to meet the daily and emergency needs of
the ASF. Clean linen shall be handled and stored to minimize contamination
from surface contact or airborne deposits.

Observations:

Based on review of policy, observation, and interview with staff (EMP) it was determined that the facility failed to ensure clean linen were handled and stored to minimize contamination from surface contact or airborne deposits

Findings include:

On April 10, 2025, review of facility policy "Linen Service/Handling " with a most recent revision date of 2011 revealed "To promote a safe environment for treating patients and to protect and safeguard from cross infection ... "

Observation on April 10, 2025, revealed clean linen stacked across a bed in Bay #8.

On April 10, 2025, an interview with EMP1 confirmed the documentation above was accurate.

Plan of Correction - To be completed: 04/30/2025

Clean linen stored on the clean stretcher in bay 8, will be protected by a plastic barrier. This will ensure that the clean linen is stored in a clean environment, minimizing surface contact and airborne deposits.

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