Pennsylvania Department of Health
NAZARETH HEALTH ENDOSCOPY CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NAZARETH HEALTH ENDOSCOPY CENTER
Inspection Results For:

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NAZARETH HEALTH ENDOSCOPY CENTER - 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 September 6, 2023, at Nazareth Endoscopy 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:


553.3 (1) LICENSURE Governing Body Responsibilities:State only Deficiency.
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.

Observations:
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to all applicable State Laws.

The facility was not in compliance with the following state law related to Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act 40 PS. Patient Safety committee...Section 310. Patient Safety committee (a) Composition ...
(2) An ambulatory surgical facility's or birth center's patient safety committee shall be composed of the medical facility's patient safety officer, and at least one health care worker of the medical facility and one resident of the community served by the ambulatory surgical facility or birth center who is not an agent, employee or contractor of the ambulatory surgical facility or birth center. No more than one member of the patient safety committee shall be a member of the facility's board of governance. The committee shall include members of the medical facility's medical and nursing staff. The committee shall meet at least quarterly."

Based on review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure no more than one member of the facility's Governing Body was a member of the facility's Patient Safety Committee.

This was not met as evidenced by:

Finding include:

Review of facility document "Patient Safety Plan/Program" last reviewed May 24, 2023, revealed "Procedure/Requirements: 1. The Patient safety committee (PSC) consists of a. The PSO (Patient Safety Officer). b. A Facility Healthcare Worker. c. A Resident of the Community who has no affiliation with the Center."

Review of facility documents "Nazareth Health Endoscopy Center Governing Body Meeting Minutes" dated November 9, 2022, January 13, 2023, June 13, 2023, and August 3, 2023, revealed EMP2 and EMP3 were members of the facility's Governing Body and was in attendance at the meetings listed.

Review of facility documents "Nazareth Health Endoscopy Center Patient Safety Committee Meeting Minutes" dated October 28, 2022, January 27, 2023, April 20, 2023, and July 21, 2023, revealed EMP2 and EMP3 were members of the facility's Patient Safety Committee and was in attendance at the meetings listed.

An interview conducted on September 6, 2023, at 11:55 AM with EMP2 confirmed EMP2 and EMP3 were members of the facility's Governing Body and Patient Safety Committee. Further interview confirmed that EMP2 and EMP3 was in attendance at the facility's Patient Safety Committee Meetings held on October 28, 2022, January 27, 2023, April 20, 2023, and July 21, 2023.




 Plan of Correction - To be completed: 10/19/2023

The Patient Safety Committee consists of the Patient Safety Officer, Nurse Administrator and a resident of the community. Other staff members may attend the Patient Safety Committee meetings provided there is not more than one member of the Governing Body in attendance. The Nurse Administrator will be responsible for monitoring the attendance of all subsequent Patient Safety Committee Meetings to assure compliance with MCARE Act 40 and the presence of only one member of the Governing Body. The attendance roster of all future Patient Safety Committee meetings will be reported to the Quality Improvement Committee.
567.1 LICENSURE Principle:State only Deficiency.
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 observation, review of facility policy and interview with staff (EMP), it was determined that the facility failed to ensure patient food supplies were maintained by the facility in a safe manner for patient use and consumption.

Findings include:

A review of facility policy "Safe Environment for Endoscopy Center" last reviewed March 23, 2020, revealed "PURPOSE: The purpose of this policy is to ensure adequate safeguards to protect patients from healthcare acquired infections and injury while under the care of the Center. PROCEDURE: ...5.i. Only patients are permitted to consume food or drink in patient care areas."

An observation tour conducted on September 6, 2023, at 10:25 AM through 11:30 AM with EMP1 revealed:

Two Gallon Size plastic bags with single serve packages of Saltine Crackers and Graham Crackers with expiration dates of March 12, 2023, and August 15, 2023 in a facility storage cabinet directly outside of the Procedure Rooms adjacent to the Endoscope Cabinet.

Two Cases of containing 12 ounce cans of ginger-ale with no date on the cases and or on the 12 ounce cans.

Two gallon size Plastic Canisters containing single service packages of Graham Crackers and single serve packages of Saltines Crackers sitting on the counter at the nurse's desk with no date on the packages.

An interview conducted on September 6, 2023, at 11:35 AM with EMP1 confirmed the observational findings observed during the tour conducted on September 6, 2023, from 10:25 through 11:30 AM. EMP1 stated "All of these items are for patient consumption.
__________

Based on observation and interview with staff (EMP), it was determined that the facility failed to ensure the handling of the high level disinfection endoscopes were transported in a safe manner to the storage cabinet.

Findings include:

An observation tour conducted on September 6, 2023, at 11:22 AM with EMP5 of the Decontamination Room revealed there was a gastrointestinal endoscope storage cabinet located outside of the Decontamination Room in the hallway corridor. Further observation revealed EMP5 transported the gastrointestinal endoscope storage cabinet without protective covering to prevent contamination.

An interview conducted on September 6, 2023, at 11: 30 AM with EMP5 confirmed the high level disinfected endoscopes were transport to the scope cabinet without the use of protective covering.






 Plan of Correction - To be completed: 10/26/2023

The manufacturer of the ginger-ale was contacted for instructions to determine the expiration or best by date of the product; the manufacturer uses the Julian Calendar to determine such dates. A Julian Calendar was placed in the storage cabinet housing the beverages, in addition to instructions for deciphering the code on the outside of the box. All dates will be marked on the outside of the box and each individual can. Graham Crackers and Saltines will be stored in plastic bags with the expiration date changed upon any new product procurement. In addition, the expiration date of all crackers will be listed on the plastic containers at the Nurses Station. A rolling cart was purchased in September to transport the high-level disinfected endoscopes to the scope cabinets. The endoscopes will be transported in covered containers. All staff were educated on the Environment of Care plan of correction with instructions for labeling beverages and nourishments with expiration dates and transporting the endoscopes, via cart, in covered containers. Education was completed on 10/13/2023 and included demonstration, discussion and Q & A. The Nurse Administrator will be responsible for monitoring the transport of endoscopes in covered containers and labeling of expiration dates on all nourishments, and will audit this process during the monthly Environment of Care rounds. The results of the Environment of Care audits will be reported to the Quality Improvement Committee at the quarterly meetings.
567.3 (b)(3) LICENSURE Policies and Procedures:State only Deficiency.
567.3 Policies and procedures

(b) Current written policies and procedures to assure definite and
valid infection control shall include,but not be limited to, the
following:
(3) Sterilization and disinfection, including suitable equipment for routine and rapid sterilization.
Observations:
Based on facility document and interview with staff (EMP), it was determined that the Governing Body failed to ensure the facility's Patient Safety Plan required no more than one member of the facility's Governing Body attended the quarterly Patient Safety Committee in compliance with the Pennsylvania State Law ACT13 (MCARE Act 13).

Findings include:

The facility was not in compliance with the following State Law related to Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act 40 PS. Patient Safety committee...Section 310. Patient Safety committee (a) Composition ...
(2) An ambulatory surgical facility's or birth center's patient safety committee shall be composed of the medical facility's patient safety officer, and at least one health care worker of the medical facility and one resident of the community served by the ambulatory surgical facility or birth center who is not an agent, employee or contractor of the ambulatory surgical facility or birth center. No more than one member of the patient safety committee shall be a member of the facility's board of governance.

Review of facility document "Patient Safety Plan/Program" last reviewed May 24, 2023, revealed "Procedure/Requirements: 1. The Patient safety committee (PSC) consists of a. The PSO. b. A Facility Healthcare Worker. c. A Resident of the Community who has no affiliation with the Center."

An interview conducted on September 6, 2023, at 10:00 AM with EMP2 confirmed the facility's Patient Safety Committee did not meet compliance with the State Law Act 13 (MCARE) for composition of committee members for the facility's Patient Safety Committee.



 Plan of Correction - To be completed: 10/26/2023

The Patient Safety Committee consists of the Patient Safety Officer, Nurse Administrator and a resident of the community. Other staff members may attend the quarterly meetings, provided there is not more than one member of the Governing Body in attendance. The Nurse Administrator will be responsible for monitoring the attendance of the Patient Safety Committee meetings to assure compliance with MCARE Act 40 and the presence of only one member of the Governing Body. The attendance roster of all future Patient Safety Committee meetings will be reported to the Quality Improvement Committee at the quarterly meetings. The Patient Safety Plan was revised to state only one member of the Governing Body may be in attendance at the quarterly meetings.

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