Pennsylvania Department of Health
LEHIGH VALLEY VASCULAR INSTITUTE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LEHIGH VALLEY VASCULAR INSTITUTE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an unannounced offsite revisit survey initiated on April 25, 2024 and completed on May 2, 2024, following a State Licensure survey completed on January 29, 2024, at Lehigh Valley Vascular Institute. It was determined that 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(8)(v) LICENSURE Governing Body Responsibilities:

553.3 Governing Body responsibilities include:
(8) Establishing personnel policies and practices which adequately support
sound patient care to include, the following:
(v) Written job descriptions shall exist for each type of job in the ASF.

Observations:

Based on review of facility documents and personnel files (PF) and staff interview (EMP), it was determined the Governing Body failed to maintain personnel policies and practices which adequately support sound patient care including written job descriptions for each type of job in the ASF

Findings include:

Review on April 25, 2024 of facility policy "Associates' Records and Files", revised January 8, 2024 revealed "2. A personnel file is maintained on each associate and contains information regarding the individual's employment, required state licensing, salary history, performance, and training records. Copies of all personnel forms, recommendations, and documentation of any disciplinary actions are also included..."

Request made on April 25, 2024 to EMP1 for a written job description for PF6. Job description titled "Adminstrator" dated April 2022. No proper job description provided. Documentation revealed, employee was hired on November 26, 2023 and worked as a Client Coordinator for the facility. Further review revealed PF6 did not have a written job description outlining duties and responsibilities.

Email interview with EMP1 on May 2, 2024 confirmed the above findings.

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

561.1 LICENSURE Drugs & Biologicals:

561.1 Drugs and Biologicals

The ASF shall provide drugs and biologicals in a safe and effective
manner to meet the needs of patients, and to adequately support the organization's clinical capabilities commensurate with their licenses classification, in accordance with accepted ethical and professional practice and applicable State and Federal law, including the Pharmacy Act (63 P.S. 390-1 -390.13), 49 Pa. Code Chapter 27 (relating tot he State Board of Pharmacy), The Controlled Substance, Drug, Device and Cosmetic ACT (35 P.S. 780-101-780-144) and Chapter 25 (relating to controlled substances, drugs, devices and cosmetics).

Observations:

Based on review of policy and procedure and interview with staff (EMP) it was determined the facility failed to ensure disposal of used medication vials, used syringes and used needles were rendered unrecoverable.

Findings include:

Request made on April 25, 2024 to EMP1 for a facility protocol that addresses the proper disposal of used medication vials, used syringes in an unrecoverable red bin. None available.

Email interview on May 2, 2024, with EMP1 confirmed "the syringes and blood stained material is packed in the red bags and picked up by Daniels for pick up." No confirmation of protocol for proper disposal directly after patient use.

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

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