Pennsylvania Department of Health
SURGERY CENTER AT FORT WASHINGTON, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SURGERY CENTER AT FORT WASHINGTON, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a full Medicare recertification survey conducted on-site beginning on April 10, 2024 and ending on April 11, 2024, at The Surgery Center at Fort Washington. It was determined the facility was in substantial compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions for Coverage for Ambulatory Surgical Centers.

Plan of Correction:

Initial comments:

This report is the result of a State licensure survey conducted on April 10 and 11, 2024, at The Surgery Center at Fort Washington. 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:

416.42 STANDARD STANDARD LEVEL TAG FOR SURGICAL SERVICES:

Surgical procedures must be performed in a safe manner by qualified physicians who have been granted clinical privileges by the governing body of the ASC in accordance with approved policies and procedures of the ASC.

Observations:

Based on observation, review of medical record (MR), and interview with staff (EMP), it was determined the facility failed to perform a fire risk assessment on patients prior to a procedure in 21 out of 21 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21) .

Findings include:

Review on April 11, 2024, of medical records (MR) revealed fire risk assessments for patients admitted for procedures requiring anesthesia between dates April 10, 2023 to April 11, 2024, were not completed in 21 of 21 medical records (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21).

Requested on April 11, 2024, from EMP3 the facility Fire Risk Assessment policy. None provided.

Interview on April 11, 2024, at 11:39 AM with EMP3 confirmed Fire Risk Assessment is not completed prior to procedures. EMP3 confirmed above findings.

Plan of Correction - To be completed: 05/03/2024

The Administrator and Director of Nursing along with the patient safety committee created a new fire risk assessment policy to comply with the updated fire risk assessment in our EMR. The policy was approved by MAB on 4/30/24 and all staff, physicians and contracted employees were in-serviced by 5/3/24. The patient's charts will be checked for compliance daily by PACU staff during the current daily chart audit. The PACU manager will report compliance to DON and Administrator weekly. The DON/ Administrator will report compliance to pt. safety committee on a quarterly basis.

416.43(d) STANDARD PERFORMANCE IMPROVEMENT PROJECTS:

(1) The number and scope of distinct improvement projects conducted annually must reflect the scope and complexity of the ASC's services and operations.

(2) The ASC must document the projects that are being conducted. The documentation, at a minimum, must include the reason(s) for implementing the project, and a description of the project's results

Observations:

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to follow their quality assurance plan for the identification of problems and actions taken - through the monitoring and evaluation process - which improve the quality of patient care.

Findings:

Review on April 10, 2024, of facility's Quality Assurance Plan reviewed December 15, 2023 revealed, "Purpose: The Quality Assurance Plan (the Plan) as delineated below provides quidelines for the conduct of an ongoing quality assessment and improvement program designed to monitor and evaluate objectively and systematically the quality and appropriateness of patient care, pursue opportunities to improve patient care and resolve identified problems".

A request was made to EMP2 on April 11, 2024, for a list of ongoing performance improvement project(s) performed by the ambulatory surgery center. None was provided.

Interview with EMP2 on April 11, 2024, at approximately 10:30 AM, confirmed the facility did not have a current or ongoing performance improvement project.

Plan of Correction - To be completed: 05/03/2024

The Administrator and Director of Nursing along with the Quality Assurance committee looked at current data to conduct a QI project on areas that need improvement. The committee chose OR fire safety and Biohazard sharps safety as areas needed to improve. The DON will collect data on compliance with the areas that need improvement for the next 3 months and report findings to the QA committee. The QA committee will decide quarterly on what areas the administration should be monitoring for evaluation and improvement.

416.44(d) STANDARD EMERGENCY EQUIPMENT:

(d) Standard: Emergency equipment. The ASC medical staff and governing body of the ASC coordinates, develops, and revises ASC policies and procedures to specify the types of emergency equipment required for use in the ASC's operating room. The equipment must meet the following requirements:

(1) Be immediately available for use during emergency situations.

(2) Be appropriate for the facility's patient population.

(3) Be maintained by appropriate personnel.

Observations:

Based on observation, review of facility policy and procedures, and interviews with staff (EMP), it was determined the facility failed to follow its procedure for completing an operating room crash cart check.

Findings include:

Observation on April 10, 2024, at 10:34 AM in the post-op recovery area revealed oxygen tank on crash cart was empty.

Review on April 11, 2024, of facility policy and document, "Emergency Medications/Cart" review date December 15, 2023, and document "Fort Washington Surgery Center - OR Crash Cart Check List " review date December 15, 2023, revealed daily crash cart checks must include " Oxygen Tank operation checked >250 psi " .

Interview on April 11, 2024, at 10:34 AM with EMP2 confirmed oxygen tank on crash cart for operating room and recovery area was empty and daily crash cart checks must include Oxygen Tank operation must be checked and greater than 250 psi.

Plan of Correction - To be completed: 05/03/2024

The Director of Nursing (DON) reviewed the policy/procedure that was not followed along with Crash cart check list and in-serviced all employees by 5/3/24. The PACU manager will check weekly that the daily OR/PACU crash cart check list is completed and followed correctly. The PACU manager will report their findings to DON monthly and the DON will report their findings to the Administrator and pt. safety committee quarterly for ongoing compliance.

416.51(a) STANDARD SANITARY ENVIRONMENT:

The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.

Observations:

Based on observation, 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 in the red biohazard containers.

Findings include:

Observation on April 11, 2024, at approximately 11:07 AM of procedural area room 136 and 141 revealed floor based, red biohazard-container that contained discarded syringes, an undetermined number of bent needles, and used syringes containing clear liquids. Further observation revealed the lid to the container was opened and the contents accessible.

Review on April 11, 2024, of facility policy and procedures, "Bloodborne Pathogens Exposure Control Plan" reviewed December 15, 2023, revealed "Used needles will not be sheared, bent, broken, recapped ... All liquid/medications that require disposal should be discarded in Drug Buster Drug Disposal System ... "

Interview on April 11, 2024, at 11:13 AM, with EMP2 confirmed above findings.

Plan of Correction - To be completed: 05/03/2024

The Director of Nursing reviewed the noncompliant policy and in-serviced all staff by 5/3/24. The OR/PACU managers will do weekly assessments on sharps container compliance with policy and procedure and report to DON any noncompliance. The DON will report compliance with policy and procedure to the Administrator monthly and to the Patient Safety committee quarterly to maintain compliance.

557.3 (b) LICENSURE QA & Improvement Program:

557.3 The Quality Assurance and Improvement Program

(b) The quality assurance program shall provide for the identification of problems and actions taken - through the monitoring and evaluation process - which improve the quality of patient care.

567.11 (6) LICENSURE Operating Suite Equipment:

567.11 Operating suite equipment

The operating suite shall be adequately equipped with age appropriate
equipment for the types of procedures to be performed and the recovery area shall
be adequately equipped for the proper care of postanesthesia recovery
of surgical patients. All equipment and supplies shall be age and size appropriate
for the patients treated. The following equipment shall be available in the operating
suite and recovery area:
(6) Resuscitator including oxygen and suction equipment

Observations:

Based on observation, review of facility policy and procedures, and interviews with staff (EMP), it was determined the facility failed to follow its procedure for completing an operating room crash cart check.

Findings include:

Observation on April 10, 2024, at 10:34 AM in the post-op recovery area revealed oxygen tank on crash cart was empty.

Review on April 11, 2024, of facility policy and document "Emergency Medications/Cart" reviewed December 15, 2023 and document "Fort Washington Surgery Center - OR Crash Cart Check List " reviewed December 15, 2023, revealed daily crash cart checks must include "Oxygen Tank operation checked >250 psi " .

Interview on April 11, 2024, at 10:34 AM with EMP2 confirmed oxygen tank on crash cart for operating room and recovery area was empty and daily crash cart checks must include Oxygen Tank operation must be checked and greater than 250 psi.

567.33 (c) LICENSURE Waste Disposal:

567.33 Waste disposal

(c) Pathological, bacteriological, surgical,
gynecological and contaminated waste and similar materials shall be
disposed of by a method approved by the Department of Environmental
Resources under 25 Pa. Code Chapter 75 (relating to solid waste management)
and in compliance with local ordinance.

Observations:

Based on observation, 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 in the red biohazard containers.

Findings include:

Observation on April 11, 2024, at approximately 11:07 AM of procedural area room 136 and 141 revealed floor based, red biohazard-container that contained discarded syringes, an undetermined number of bent needles, and used syringes containing clear liquids. Further observation revealed the lid to the container was opened and the contents accessible.

Review on April 11, 2024, of facility policy and procedures, "Bloodborne Pathogens Exposure Control Plan" reviewed December 15, 2023, revealed "Used needles will not be sheared, bent, broken, recapped ... All liquid/medications that require disposal should be discarded in Drug Buster Drug Disposal System ..."

Interview on April 11, 2024, at 11:13 AM, with EMP2 confirmed above findings.

569.3 LICENSURE Policies and Procedures:

569.3 Policies and Procedures

Written policies and procedures for use in preventing and
responding to fire and disaster shall be made available to personnel.

Observations:

Based on observation, review of medical record (MR), and interview with staff (EMP), it was determined the facility failed to perform a fire risk assessment on patients prior to a procedure in 21 out of 21 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21) .

Findings include:

Review on April 11, 2024, of medical records (MR) revealed fire risk assessments for patients admitted for procedures requiring anesthesia between dates April 10, 2023 to April 11, 2024, were not completed in 21 of 21 medical records (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21) reviewed during the time periord of April 10, 2023 and April 11, 2024.

Requested on April 11, 2024, from EMP3 the facility Fire Risk Assessment policy. None provided.

Interview on April 11, 2024, at 11:39 AM with EMP3 confirmed Fire Risk Assessment is not completed prior to procedures. EMP3 confirmed above findings.

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