Pennsylvania Department of Health
SURGERY CENTER OF LANCASTER, LLC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SURGERY CENTER OF LANCASTER, 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 February 8, 2024, at Surgery Center of Lancaster. 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:

555.24 (g) LICENSURE Surgical Services - Postoperative:

555.24 Post Operative Care

(g) Patients shall be discharged only upon the written signed order of a practitioner.

Observations:

Based on review of facility documents, medical records (MR), and employee (EMP) interview it was determined the facility failed to ensure a patient was discharged upon written order of a practitioner in one out of 10 MR reviewed (MR6).

Findings include:

On February 8, 2024, a request was made to the facility for a discharge policy that noted patient's shall be discharged upon written signed order of a practitioner. None was provided.

On February 8, 2024, review of MR6 revealed there was no documentation of a physician ' s order written for discharge from the surgery center.

Interview with EMP1 on February 8, 2024, EMP1 confirmed that the discharge order was missing from MR6 and the facility does not have a policy that notes a patient shall be discharged upon written signed order of a practitioner.

Plan of Correction - To be completed: 03/15/2024

On 2/12/2024, the current policy "Discharge of a Patient from the PACU" was updated to include the following: "Patients shall be discharged only on the signed written order of a practitioner." This updated policy will take effect immediately. Education will be provided in the form of printed updated policy review, review of chart check process, and 1:1 discussion with PACU staff. Following this education, focused discharge order review of 10 charts per week by the Quality Coordinator will occur alongside the daily chart check to confirm the updated policy is being adhered to. Once 100% compliance is achieved, the process of daily chart reviews will continue by PACU staff. This Plan of Correction will be completed by March 15, 2024.

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 facility documents, observation, and employee (EMP) interview it was determined the facility failed to ensure instruments/equipment are being cleaned and disinfected properly to protect the health and safety of patients according to manufacture guidelines.

Findings include:

On February 8, 2024, review of facility "Infection Control Plan" revealed "Sterile Processing (SP) Sterile processing of surgical instruments and devices is carried out onsite by the facility healthcare personnel (HCP). The facility does not reprocess any single-use devices. HCPs have access to surgical instrument/device and sterile reprocessing equipment manufacturer instructions for use (IFU)s located in the Sterile Processing Department (SPD). Critical water (i.e., water that is treated to remove microorganisms, organic, and inorganic material e.g., treated with filtration, reverse osmosis, deionization, sterilization) and meets predetermined water quality parameters, is used in accordance with surgical instrument and sterile reprocessing equipment manufacturer IFUs."
On February 8, 2024, review of facility document "Decontamination" located on the wall in the facility SPD over the sink where instruments are cleaned revealed "Cleaning Process ... Presoaking for 2 min. with 1 ounce of Enzyme detergent with a PH level between 7-9, in 1 gallon of tap water. Inside cleaning basin is marked showing 1 gallon level. 1 complete pump = 1 ounce Enzyme detergent. Washing manually and/or mechanically according to IFU and by a process specifically designed for surgical instruments."

On February 8, 2024, review of facilities "Endozime AW"guidelines revealed one-half ounce of the enzymatic detergent is to be used with one gallon of water.

Interview with EMP2 on February 8, 2024, EMP2 confirmed when cleaning instruments 1/2 pump of the Endozime AW is deposited in one gallon of water to adhere to manufactures guidelines. EMP2 also confirmed a measuring cup/tool is not used to ensure 1/2 pump equals 1/2 ounce.

Observation noted on February 8, 2024, EMP2 deposited one full pump of Endozime AW into a measuring cup totaling one half ounce of detergent.

Interview with EMP1 on February 8, 2024, EMP1 confirmed the one full pump of Endozime AW enzymatic detergent in the measuring cup totaled one half ounce and the facility was not adhering to manufacturer's guidelines by depositing 1/2 pump of Endozime AW into a gallon of water. EMP1 also confirmed the facility document "Decontamination" does not align with manufacturers guidelines.

Plan of Correction - To be completed: 02/22/2024

During DOH visit on February 8, 2024, "Decontamination" document hanging over the sink in SPD showed information that was no longer correct, and was removed by SPD staff the same day. The Manufacturer's IFU for Endozime AW Plus was reviewed, and a corrected instruction sheet was created and hung in SPD. All SPD staff were/will be educated on the correct dilution and use of the product (via 1:1 education), as well as the necessity to speak with a Manager following any future product change. To ensure proper dilution, a designated measuring cup was placed next to the enzymatic solution and is being used moving forward. These measures were implemented immediately. Staff education will be ongoing and completed by February 22, 2024.

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