Pennsylvania Department of Health
HARRISBURG ENDOSCOPY AND SURGERY CENTER, INC.
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HARRISBURG ENDOSCOPY AND SURGERY CENTER, INC. - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a full Medicare recertification survey conducted on May 8, 2024, at Harrisburg Endoscopy and Surgery Center. It was determined the facility was in substantial compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions for Coverage for Ambulatory Surgical Centers.

Plan of Correction:

Initial comments:

This report is the result of a State licensure survey conducted on May8, 2024, at Harrisburg Endoscopy and 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:

416.50(f)(2) STANDARD SAFETY:

[The patient has the right to -]

(2) Receive care in a safe setting

Observations:

Based on review of facility documents, observations, and staff interview (EMP) it was determined the facility failed to ensure patients received care in a safe setting by not providing patients with a call bell to notify staff the need for assistance.

Findings include:

On May 9, 2024, review of facility policy "Description of Services" last review January 30, 2024, revealed "Environment - E. A safe environment for treating patients including adequate safeguards to protect the patient from cross-infection is insured through the provision of adequate space, equipment, and personnel. ..."

1. Observation on May 9, 2024, of Pre-Op bays eight (8), nine (9), and 13 patients noted to be on stretcher with privacy curtains drawn on each side not in eyesight of nursing station. Call bell was out of reach and out of sight of patient, attached to wall behind patient with cord tied in knot.

2. Observation on May 9, 2024, of Post-Op bays one (1) and three (3) patients noted to be on stretcher with privacy curtains drawn on each side not in eyesight of nursing station. Call bell was out of reach and out of sight of patient, attached to wall behind patient with cord tied in knot.

Interview with EMP1 on May 9, 2024, confirmed patient call bells were out of sight and reach of patients in Pre-Op bays 8, 9, 13 and Post-Op bays 1 and 3.

Plan of Correction - To be completed: 05/22/2024

On May 17, 2024, an Inservice was performed for all nursing staff. The Inservice was to educate all nursing staff on the assurance of providing all patients with their Call Bell. The Inservice instructed the nursing staff on how to provide the patient with their Call Bell and how to utilize the Call Bell when needed. All nurses completed the Inservice on May 20, 2024, but one staff nurse did not complete the Inservice, since she is deployed on active duty with the PA National Guard. Upon her return to the facility, she will be instructed on the Call Bell for patients and her name will be added to the Inservice Sheet.
The Director of Nursing at Harrisburg Endoscopy & Surgery Center will perform a Quality Check, to verify compliance for the Call Bell being provided to every patient. The Quality Check will be done daily and a log kept for one month. Thie Quality Check will start on May 21, 2024 until June 21, 2024. If a staff nurse is found to be out of compliance, then the staff member will be re-educated and the Quality Check will be extended for one more month.

416.51(a) STANDARD SANITARY ENVIRONMENT:

The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.

Observations:

Based on review of facility documents, observation, and employee (EMP) interview it was determined the facility failed to ensure a sanitary environment was maintained by adhering to professionally acceptable standards of practice.

Findings include:

On May 9, 2024, review of facility policy "Personal Protective Equipment PPE" last reviewed January 30, 2024, revealed "Personal Protective Equipment: The type of protective apparel chosen depends on the clinical situation and the type of patient care anticipated. The selection of barrier protection, equipment, or work practice should include consideration of following issues: Probability of exposure to blood and body substances, Amount of blood and body substances likely to be encountered, Probable route of transmission Gloves- Gloves must be changed when soiled or punctured, and prober hand hygiene must be followed when gloves are removed."

1. On May 9, 2024, observation of EMP2 did not charge soiled gloves after performing the task of Endoscopy and moving to the next task of Colonoscopy.

2. On May 9, 2024, observation of EMP3 did not change soiled gloves after assisting EMP2 with the task of Endoscopy and moving to the next task of assisting with Colonoscopy.

3. On May 9, 2024, observation of EMP3 did not change soiled gloves after assisting with Colonoscopy and moving to the next task of cleaning the endoscopy scope.

Interview with EMP1 on May 9, 2024, EMP1 confirmed the above observations does not follow policy.

Plan of Correction - To be completed: 05/22/2024

On May 30, 2024, all endoscopy room staff had completed an Inservice on Glove Changing while moving to the next task. The Inservice included the proper way to change gloves when moving to the next task during an endoscopy procedure. The staff was educated on how to change gloves and when to change gloves. All physicians who are credentialed at Harrisburg Endoscopy & Surgery Center, also received and Inservice on Changing Gloves when performing the next task. This involved the changing of gloves during and EGD/Colonoscopy procedure. All physicians had completed the Inservice by May 21,2024. A list of the physicians who completed the Inservice are kept in the Inservice Manual. All Endoscopy Room staff who completed the Inservice are listed in the Inservice Manual as well.
The Lead Technologist at Harrisburg Endoscopy & Surgery Center will perform a Quality Check on implementation of the glove changing after moving to the next task. The Quality Check will be daily and a log kept for one month, starting May 21, 2024 until June 21, 2024. If any staff member or physician fails to comply with the Changing of Gloves, then the staff member or physician will be re-educated, regarding the Glove Changing while moving to the next task and the Quality Check will be extended for one more month

553.12 (b)(7) LICENSURE Implementation:

553.12
(b) The following are the minimal provisions for the patient's bill of
rights:
(7) The patient has the right to good quality care and high
professional standards that are continually maintained and reviewed

Plan of Correction - To be completed: 05/22/2024

On May 17, 2024, an Inservice was performed for all nursing staff. The Inservice was to educate all nursing staff on the assurance of providing all patients with their Call Bell. The Inservice instructed the nursing staff on how to provide the patient with their Call Bell and how to utilize the Call Bell when needed. All nurses completed the Inservice on May 20, 2024, but one staff nurse did not complete the Inservice, since she is deployed on active duty with the PA National Guard. Upon her return to the facility, she will be instructed on the Call Bell for patients and her name will be added to the Inservice Sheet.
The Director of Nursing at Harrisburg Endoscopy & Surgery Center will perform a Quality Check, to verify compliance for the Call Bell being provided to every patient. The Quality Check will be done daily and a log kept for one month. The Quality Check will start on May 21, 2024 until June 21, 2024. If a staff nurse is found to be out of compliance, then the staff member will be re-educated and the Quality Check will be extended for one more month

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.

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