Pennsylvania Department of Health
SPARTAN HEALTH SURGICENTER, LLC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 32 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


SPARTAN HEALTH SURGICENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
This report is the result of a State licensure survey conducted on April 22, 2025, at Spartan Health Surgicenter. 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:

561.22 (a) LICENSURE Records:

561.22 Records

(a) Drug transactions of the pharmaceutical service shall be recorded, and those records shall be
correlated with other ASF records. Records and security shall be maintained to assure the control and
safe dispensing and compliance with Federal and Commonwealth statutes.

Observations:

Based on facility documents, tour of the facility, and employee interview (EMP), it was determined that the facility failed to ensure recording of drug transactions and safe control of medication in the narcotic storage drawer.

Findings include:

Review of facility policy, "Narcotic and Controlled Substances" from the Pharmacy Manual, no date, revealed: "1. All narcotics will be under double-lock at all times. 2. ... On days that Spartan Health Surgicenter has procedures a narcotic count will be performed in the am and another count at the end of the day by either the director of nursing or charge nurse and another R.N. or CRNA or M.D. ..."

Observational tour of the facility on April 22, 2025, at 1:20 PM, revealed that the end-of-day entry on the narcotic count sheet had been completed. There was one set of initials next to the recorded narcotic counts, missing a co-signature per facility policy.

This was confirmed by EMP2 at 1:30 PM.

Continued evaluation of the medication area included single-lock storage for two narcotic medications "Versed" and "Fentanyl" within the drawer was a syringe containing approximately 2.1-2.2 milliliters of clear fluid. An orange sticker was adhered to the syringe and labeled "VERSED". There was no date, time, initial, expiration, or lot number on the syringe of clear fluid. This fluid was included in the end-of-day count on the narcotic count sheet.

This was confirmed by EMP2 at 1:30 PM.

Plan of Correction - To be completed: 05/13/2025

On the subject of the narcotic count book, nursing and anesthesia staff have been educated and reviewed the Spartan narcotic count policy and count sheets on April 28. The Spartan DON will oversee that the clinical staff ensures two (2) qualified clinicians to count each day: at the beginning and end of every shift. The clinicians responsible will be a CRNA/RN, CRNA/CRNA or RN/RN.
QA for 90 days starting April 28 and ongoing every 30 days. Objective is 100% compliance within 90 days. Counts by 2 qualified clinicians who will initial and sign. All medications drawn up will be discharged with a witness.
Versed and fentanyl medications and syringes will be appropriately disposed of and witnessed by a RN/CRNA.

563.12 (5) LICENSURE Form and Content of Medical Record:

563.12 Form and content of record

The ASF shall maintain a separate medical
record for each patient. Each record shall be accurate, legible and
promptly completed. Patient medicals shall be constructed to stand alone and be easily identified as ASF records. Medical records must include at least the following:
(5) Documentation of properly executed, informed patient consent.

Observations:

Based on review of facility policy, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure the documentation of a properly executed, informed consent occurred for four of ten medical records reviewed (MR1, MR2, MR2, and MR4).

Findings include:

On April 22, 2025, review of facility policy titled "Patient Consent", last revised April 2005, revealed "... A valid consent will be obtained for all patients receiving surgical and anesthesia procedures. Procedure: 1. Persons able to give consent are: a. Adults who are age 18 or older and who are conscious and have sufficient mind to understand the nature of the proposed surgical treatment and risks of the treatment. 2. If the patient is a minor (under age 18): a. The informed consent must be provided by the parent or legal guardian".

On April 22, 2025, review of MR1, date of service April 1, 2024, revealed, the surgical consent, dated April 1, 2024 at 9:23 A.M. was only signed by the 14 year old minor patient and not the parent or legal guardian.

On April 22, 2025, review of MR2, date of service December 27, 2024, revealed, the surgical consent, dated December 27, 2024 at 7:34 A.M. was only signed by the 15 year old minor patient and not the parent or legal guardian.

On April 22, 2025, review of MR3, date of service September 25, 2024, revealed, the surgical consent, dated September 25, 2024 at 12:43 P.M. was only signed by the 17 year old minor patient and not the parent or legal guardian.

On April 22, 2025, review of MR4, date of service April 11, 2024, revealed, the surgical consent, dated April 11, 2024 at 07:00 A.M. was only signed by the 16 year old minor patient and not the parent or legal guardian.

On April 22, 2025, at 1:20 P.M. EMP2 confirmed the above findings.

Plan of Correction - To be completed: 05/13/2025

On the subject of patient consent, on April 28, the Spartan nursing staff have been educated on this DOH survey finding. The Spartan consent policy has been reviewed by the DON and nursing staff.
QAPI will be conducted monthly. Each month 10% of patient charts will be reviewed for 90 consecutive days or until Spartan reaches 100% compliance for a period of not less than 90 consecutive days.

567.41 LICENSURE MAINTENANCE SERVICE - Principle:

567.41 Principle

The ASF shall be equipped, operated and maintained to sustain its
safe and sanitary characteristics and to minimize health hazards in the ASF
for the protection of patients and employes.

Observations:

Based on a tour of the facility and employee interview (EMP), it was determined that the facility failed to equip, operate, and/or maintain a safe and sanitary environment in multiple areas of the facility.

Findings include:

On April 22, 2025, between 10:30 AM and 12:15 PM, an observational tour was conducted throughout the facility and revealed a surgical space consisting of four operating rooms and three procedure rooms.

A tour of the pre-operative area at 10:30 AM revealed three patients awaiting services in bays #1, #6, and #7. The patients located in bays #6 and #7 were connected to continuous vital sign monitoring. Both bays revealed the nurse call bell hanging on the wall, two to three feet behind the stretcher, out of patient reach.

This finding was confirmed by EMP2 at 10:47 AM.

A tour of the OR (Operating Room) and PR (Procedure Room) area between 10:50 AM and 12:00 PM revealed concerns related to accurate temperature and humidity measurement devices in four out of four rooms observed. An additional electronic measurement device was brought into each space to confirm this finding and was placed in the center of the room, allowing time to measure the environment.

OR #1 revealed equipment which read 72 degrees F (Fahrenheit) and 70 percent RH (relative humidity) at 10:55 AM.

The electronic measurement device revealed 68 degrees F and 40 percent RH at 11:10 AM.

OR #4 revealed equipment which read 70 degrees F and 50 percent RH at 11:25 AM.
The electronic measurement device revealed 74 degrees F and 37.5 percent RH at 11:30 AM.

PR #1 revealed equipment which read 66 degrees F and 66 percent RH at 11:50 AM.
The electronic measurement device revealed 71.5 degrees F and 37 percent RH at 11:55 AM.

PR #4 revealed equipment which read 82 degrees F and 48 percent RH at 12:00 PM.
The electronic measurement device revealed 73.3 degrees F and 36 percent RH at 12:05 PM.

These findings were confirmed by EMP2 between 11:00 AM and 12:05 PM.

Continued tour of the patient areas revealed:

OR #1 revealed an unsecured, alcohol-based odor eliminator, "Bye-Bye-Odor" on top of the anesthesia cart.

The sterilization room revealed incomplete weekly emergency eyewash station logs for four weeks of April 2025.

The housekeeping storage closet contained three bags of garbage on the floor, which were not in cleanable containers with tight-fitting lids.

Four out of four patient restrooms revealed emergency assist cords which were wrapped or tied around the safety handrail, preventing them from being pulled by a patient in need of help (pre-op, post-op, waiting area men's room and ladies room).

These findings were confirmed by EMP2 between 11:00 AM and 12:10 PM.

Plan of Correction - To be completed: 05/13/2025

On the subject of observation #6744, on April 28 the Administrator and DON have purchased thermometer/clock/humidity monitors for each area. The facility HVAC contractor has been contacted April 28 and corrected the issue and will be assigned to monitor this issue for the next 90 days.
These areas will be checked every day with the new thermometers by Spartan staff.
The Spartan staff has been educated on April 28.
Spartan staff educated on ranges and documentation standards of temperature and humidity, and what to document if temperature and humidity levels are out of range and specific action to be taken.
QAPI will be conducted monthly or until 100% compliance is achieved for 90 days.
On the subject of patient safety, the DON educated the Spartan staff patient safety and operating room safety.
Call light policies were reviewed. Spartan staff educated on proper placement of patient call light cords with cord location readily available to the patient.
All operating rooms are equipped alcohol-free sanitizers as of April 28.
QAPI will be conducted for 90 days or 100% compliance for 90 days.

On patient charts undated and unsigned, on April 28 the Administrator and DON sent letters out to all physicians with regard to Spartan's recent Department of Health survey on April 22. All medical records must be appropriately timed, dated, and completed with signature.
QAPI will be conducted monthly, 10% of the patient charts will he reviewed for 90 days or until 100% compliance for 90 consecutive days.

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