Pennsylvania Department of Health
RIDDLE SURGICAL CENTER, 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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RIDDLE SURGICAL CENTER, 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 May 8, 2024, at Riddle Surgical Center, LLC. 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:

567.43 LICENSURE Ventilation System:

The ventilation system shall be inspected and maintained in accordance with the written maintenance schedule to ensure that a properly conditioned air supply meeting minimum filtration, humidity and temperature requirements is provided in critical areas such as the surgical and recovery suites under
Chapter 571 (relating to construction standards).

Observations:

Based on review of facility policy, facility documents, and staff interview (EMP), it was determined the facility failed to consistently maintain the required humidity level in 4 of the facility's Operating Rooms (OR) including OR1, OR2, OR3 and OR4. The facility failed to take corrective action when the humidity readings were out of the acceptable range.

Findings include:

Review of facility's policy "UTMP.04 - HVAC O.R." last revised 7/7/2020, revealed "... Temperature (68-75), humidity (30% - 60%) and airflow in the O.R.(s) shall be maintained within acceptable standards to inhibit microbial growth, reduce risk of infection, control odor, and promote patient comfort. The ASC shall maintain records that demonstrate they have maintained acceptable HVAC standards. Personnel who identify an unintentional variance in the predetermined HVAC system parameters must report the variance as soon as it is identified. The following steps should be followed when reporting any unintentional HVAC variance ... 5. Facilities personnel will document the correction on the daily report and file in the HVAC log book ..."

A review on May 8, 2024, of operating rooms (OR) one, two, three, and four revealed the following humidity levels with no documentation on the HVAC log of any corrective action:
February 15, 2024: OR1 26.3%; OR2 25.3%; OR3 36.2%; OR4 22.9%.
February 18, 2024: OR1 19.3%; OR2 17.7%; OR3 25.8%; OR4 24.7%.
April 7, 2024: OR1 19.6%; OR2 19.4%; OR3 20.7%; OR4 21.4%.
April 21, 2024: OR1 27.1%, OR2 26.8%; OR3 27.7%; OR4 28.6%.
April 23, 2024: OR1 28.1%; OR2 27.7%; OR3 28.5%; OR4 29.5%.

Interview with EMP1 on May 8, 2024, confirmed the above findings.

Plan of Correction - To be completed: 05/16/2024

It is the Administrator and Facility Director's responsibility to ensure corrective actions are complete, monitored and sustained.

Riddle Surgical Center will consistently maintain the required humidity level in OR1, OR2, OR3 and OR4 as noted in the HVAC O.R. policy (UTMP.04). The facility will take corrective action when the humidity reading is out of range and document the correction on the daily report, and file in the HVAC Log Book.

1. The Facility Director and Administrator will review HVAC O.R. Policy.
2. The facility team will document all adjustments made in the HVAC Log Book by adding documentation next to each humidity that is adjusted.

3. The HVAC Log book will be up to date within 24 hours of adjustments.

4. The administrator will audit the HVAC log book weekly to assure compliance.

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