Pennsylvania Department of Health
TURK'S HEAD SURGERY CENTER, L.L.C.
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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TURK'S HEAD SURGERY CENTER, L.L.C. - 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 condcuted on January 3, 2025, and concluded on January 16, 2025, at Turk's Head Surgery Center, L.L.C. 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:

569.35 (7) LICENSURE General Safety Precautions:

569.35 General Safety Precautions
The following safety precautions shall be met:
(7) Only nonflammable agents may be present in a surgical suite.

Observations:

Based on review of facility documents, and staff interview (EMP), it was determined the facility failed to ensure Physicians completed mandatory annual education regarding the use of surgical skin preparations that contain combustible agents.

Findings include:

Review on January 16, 2025, of the facility's granted Exception Request, dated February 1, 2008, for the use of surgical skin preparation which contain combustible agents revealed "... that only nonflammable agents may be present in the surgical suite. You have completed the process established by the Department for requesting an exception to this regulation and agreed to the following: ... The facility shall institute annual mandatory education provided to all staff, including the physician staff, involved in the use of surgical skin preparations that contain combustible agents. The content of the education provided and documentation of same will be reviewed by the Department during survey activity ..."

Review of the "Medical Staff Annual Education Policy Created: 2018 Policy Statement - The facility requires credentialed medical staff to complete annual Alcohol Based Skip Prep education and ... Procedures I. The Director of Nursing or Designee will coordinate ongoing annual education for all credentialed medical staff including the following: A. Alcohol Based Skin Prep: ..."

Review of facility education on January 16, 2025, at approximately 11:15 AM, revealed in the facility's Physician Education binder that there was no Alcohol Based Skin Prep education provided for the 2024 year.

Interview with EMP1 on January 16, 2025, at approximately 11:30 AM, confirmed there was no Physician Alcohol Based Skin Prep education provided for the 2024 year.

Plan of Correction - To be completed: 02/28/2025

The 2025 annual education for all staff including employed clinical staff and credentialed physicians and allied health professionals, regarding use of Alcohol Based Skin prep products was initiated 1/15/25.

The Clinical Director will ensure that the 2025 education will be completed for all staff by February 28, 2025. Evidence of completed training will be filed in the annual education binder.

Following completion of the annual education, ongoing education will be monitored for a period of 90 days to ensure that new medical staff members have completed the education for medical staff appointment.

Completion of annual and ongoing medical staff education will be reviewed at QAPI meetings.

The Administrator will annually follow up with the Clinical Director to ensure that the training is completed and that the center is adhering to the requirements established in the 2/1/2008 exception received.

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