Pennsylvania Department of Health
NEW BRITAIN SURGERY 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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NEW BRITAIN SURGERY CENTER, LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an on-site State licensure survey conducted on May 1, 2024, at the New Britian Surgery 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:

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 policies and procedures, observation and interview with staff (EMP), it was determined the facility failed to ensure a safe and sanitary environment for the provision of patient care, as evidenced by not providing a designated clean medication preparation area that is not adjacent to potential sources of contamination.
Findings include:
A request was made to EMP1 on May 1, 2024, at 10:33 AM for policy and procedure regarding medication preparation areas in the facility. None provided.
An observational tour conducted on May 1, 2024, at 10:21 AM of the pre-operative area with EMP1 revealed the following:
An observation at 10:32 AM in pre-operative area revealed on a countertop labeled "medication prep [preparation] area." Further observation revealed a sharps disposal container secured to the wall directly above and adjacent to the medication preparation area. Further observation revealed a registered nurse bringing over a sample of blood to the blood glucose meter, which was adjacent to the medication prep area.
An interview on May 1, 2024, at 10:34AM with EMP1 confirmed the sharps container and the blood glucose meter were adjacent to the medication prep area and could be a potential source of contamination of the medication prep area. Further interview revealed the facility did not have a policy on medication preparation areas.

Plan of Correction - To be completed: 06/21/2024

1) Clinical Policy 229, Medication Preparation Area, has been created and was approved by the Board of Directors on 5/20/2024 and effective immediately. The new policy has been assigned to the clinical staff via Medtrainer , which will capture their signature confirming receipt of the Policy.
2) The area designated as the medication preparation area has been reorganized with plastic barriers put in place to avoid any potential cross-contamination between the blood glucose monitor, sharps container, and medication preparation area.
The Infection Control Officer will monitor compliance on a monthly basis and report his findings to the Infection Control committee. The Administrator will review the results with the Medical Advisory Committee and Board of Directors on a quarterly basis.

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