Observations:
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to comply with the required criteria as detailed in the exception letter granting the facility use of Surgical Skin Preparations that contain Combustible Agents.
Findings include:
Review of the letter approving the exception request dated June 15, 2012, sent to Roxborough Memorial Hospital from the "Department" 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 ... ."
On February 20, 2024, a request was made by the surveyor to the facility for evidence of the required documentation of the annual mandatory education provided to all surgical staff inclusive of physician staff for the use of skin preparations that contain combustible agents. The facility was unable to provide evidence of documentation that annual mandatory education for the years 2022 and 2023 was completed for all surgical staff inclusive of physician staff.
An interview conducted on February 20, 2024, at 1:15 PM with EMP5 confirmed the facility was unable to provide evidence of documentation that the annual mandatory education for all surgical staff inclusive of physican staff involved in the use of surgical skin preparation that contain combustible agents was completed annually for the years 2022 and 2023 as required by the "Department".
| | Plan of Correction - To be completed: 04/30/2024
Roxborough Memorial Hospital, including the Medical Staff and Governing Board, will ensure the plan of correction is implemented, monitored, and managed. The Director of Surgical Services will ultimately be responsible for the plan of correction to address noncompliance with documenting annual mandatory combustible agents (surgical skin preparations) education.
The following actions have taken place: The policy, Preoperative Skin Prep, was revised to include a statement addressing education. "Medical staff and employees who use alcohol-based skin preparations in areas with potential ignition sources are educated in the proper application and use of the solutions upon hire and annually." This was completed 2/22/2024.
All employed OR staff have received education and have signed off acknowledging that they received the education. This was completed 2/21/2024. Going forward, annual education is now assigned to all employed OR staff via the electronic education system. This has been assigned as additional education for 2024, with a due date of 3/28/2024. This education will continue to be assigned upon hire and annually going forward to all employed OR staff. Documentation of completed education for employed OR staff will be kept within the electronic education system.
All physicians utilizing surgical skin preparations have received education and have signed off acknowledging that they received the education. This was completed 3/12/2024. The Medical Staff Office will be responsible for physician education with sign off upon credentialing and annually going forward. Provider education will be kept in their Medical Staff file.
Compliance will be tracked by weekly monitoring through the electronic education system. The Director of Surgical Services and each employee will receive email notification that education is assigned with an approaching due date and for any delinquent employees. Physician compliance will be monitored by running a monthly expirable report within our credentialing software, MD Staff.
Any employee that does not complete the education by the due date will be removed from the schedule until completed. Human Resources will be made aware of any noncompliant employees. Any provider that does not complete their education will not be permitted to participate in a procedure until completed. Medical Staff will be made aware of any noncompliant physicians.
The results of the monitoring will be submitted to the Quality Committee on a monthly basis, Medical Executive Committee on a monthly basis, and Governing Board on a quarterly basis. This documentation will be available within the minutes.
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