51.31. Principle
The Department may grant exceptions to this part when the policy and objectives contained therein are
otherwise met, or when compliance would create an unreasonable hardship and an exception would not impair or endanger the health, safety or welfare of a patient or resident. No exceptions or departures from this part will be granted if compliance with the requirement is provided for by statute.
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Observations:
Based on review of facility documents, credential files (CF), and interview with staff (EMP), it was determined the facility failed to comply with the required criteria as stated in the facility document "Approval of the Exception Request" granted by the "Department" for the use of surgical skin preparations that contain combustible agents.
Findings include:
Review on September 6, 2023, of facility document "Approval of the Exception Request" dated December 21, 2012, sent to American Access Care of South Philadelphia, LLC-Azura Vascular Surgery Center, revealed "...The facility shall institute annual mandatory education provided to all staff, including the physician staff, involved in the use of surgical skin preparations that contain combustible agents. The content of the education provided and documentation of same will be reviewed by the Department during survey activity. "
A request was made for the "Annual Mandatory Education" for CF1, a provider, approved by the Governing Body for a two year medical staff appointment commencing April 2022 through April 18, 2024. The facility was unable to provide the annual mandatory education for the use of surgical skin preparations that contain combustible agents as requested by the survey team as of the date of the on-site survey for CF1.
A request was made for the "Annual Mandatory Education" for CF2, certified registered nurse anesthetist, approved by the Governing Body for a two year medical staff appointment commencing April 2022 through April 18, 2024. The facility was unable to provide the annual mandatory education for the use of surgical skin preparations that contain combustible agents as requested by the survey team as of the date of the on-site survey for CF2.
A request was made for the "Annual Mandatory Education" for CF3, certified registered nurse anesthetist, approved by the Governing Body for a two year medical staff appointment commencing April 2022 through April 18, 2024. The facility was unable to provide the annual mandatory education for the use of surgical skin preparations that contain combustible agents as requested by the survey team as of the date of the on-site survey for CF3.
An interview conducted on September 6, 2023, with EMP1 confirmed the facility was unable to provide the annual mandatory education for the use of surgical skin preparations that contain combustible agents for CF1, CF2 and CF3 as requested by the survey team and as required according to the "Approval of the Exception Request" dated December 21, 2012, approved by the "Department".
| | Plan of Correction - To be completed: 12/31/2023
Corrective Action: The current deficiency will be corrected by annual education regarding surgical skin preparations with combustible agents to all clinical staff, physicians and Allied Health Practitioners (AHP's). This training was initiated on 12/7/23 and will be completed and reported on or prior to 12/20/23 at facility's Quality Committee meeting.
To prevent the reoccurrence, this annual education requirement has been added to each individual staff, physician, and AHP members annual competency checklist along with mandatory annual education roster/log for all clinical staff, physicians and AHP's as Required Annual Education. The review of this roster/log will become part of the Facility Administrator's annual Q1 audit which will be reported annually to the Governing Body during the annual meeting conducted in Q1 no later than 4/30 each year. All instances of non-compliance will be addressed by the Facility Administrator and Medical Director.
Monitoring Activities: The Facility Administrator will audit files for completeness annually during the first quarter and provide an annual report to the Quality Committee and the Governing Body at the annual Q1 meeting no later than 4/30 each year.
Responsible Party: Director of Nursing, Facility Administrator and Medical Director.
Corrective action will be completed by: 12/31/23.
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