Observations:
Based on review of facility policy and interview with staff (EMP), it was determined the facility failed to adhere to acceptable standards of practice for ensuring provision of a safe and sanitary dedicated environment (Decontamination Room) within the facility for the cleaning process and reprocessing of Scopes utilized for Fiberoptic Endoscopic Evaluation of Swallowing procedures for patients.
Findings include:
Review of facility policy "GSPP Procedural Guidelines Therapy Policy Manual-G 1-07-20" revealed "Scope: Outlines the processing and reprocessing of the Fiberoptic Endoscopic Evaluation of Swallowing (FEES) scope and requirements for documentation. ...11. PROCEDURE: Tuttleman: Central Processing Department (CPD) Process, a. Leak Testing, and Cleaning process using [XXX-enzyme] completed."
An email communication dated November 29, 2023, at 5:18 PM authored by EMP2 revealed "Good Shepherd Penn Partners Specially Hospital at Rittenhouse (GSPP) contracted with [XXXX-facility] located in the Tuttleman Building to have FEES Scopes reprocessed and sterilized at the [XXXX-facility] in their Central Processing Department in the late fall of the 2019."
A telephone interview conducted on November 29, 2023, with EMP2 confirmed the above findings. EMP2 also confirmed the facility did not have approval from the "Department" to conduct off-site processing and reprocessing for cleaning FEES Scopes.
| | Plan of Correction - To be completed: 02/29/2024
On January 8, 2024, the Speech Language Pathologists at Good Shepherd Penn Partners discontinued using the NPL endoscopes for Fiberoptic Endoscopic Evaluation for Swallowing (FEES) procedures and will use disposable endoscopes only. Good Shepherd Penn Partners (GSPP) has a supply of disposable scopes ready for use and will continue to order the disposable scopes regularly to ensure sufficient supply is available.
The adjustment to the FEES procedure was communicated on January 8, 2024, to the GSPP Therapy Department, Materials Management, the external contracted Central Processing Department, GSPP medical staff, and GSPP leadership.
To ensure there were no other areas of non-compliance with the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code Part IV Subparts A and B, 51.31 "Principle" and 51.33 "Requests for Exceptions," the Regulatory Department of Good Shepherd Penn Partners evaluated Pennsylvania Department of Health regulations relative to the services GSPP provides and determined there were no other known services or lack of services provided that would require an exception. This review was completed on December 31, 2023.
The Director of Patient Safety, Risk, and Regulatory and the Regulatory Manager are responsible for the oversight of this Plan of Correction and will communicate, report and educate the Board of Directors, GSPP Corporate Compliance Committee and Clinical Leadership of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B when making decisions to add or change services.
Upon approval of this Plan of Correction, GSPP will submit an exception request related to regulation 149.3 Facilities. The GSPP governing body was made aware of the need to apply for an exception and approved moving forward with this process.
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