Pennsylvania Department of Health
PPSP FAR NORTHEAST HEALTH CENTER
Patient Care Inspection Results

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PPSP FAR NORTHEAST HEALTH CENTER
Inspection Results For:

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PPSP FAR NORTHEAST HEALTH CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


This report is the result of an Annual Registration survey conducted onsite on November 28, 2023 and completed offsite on November 30, 2023, at Ppsp Far Northeast Health Center. It was determined the facility was in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.












 Plan of Correction:


Initial comments:


This report is the result of a State licensure survey conducted onsite on November 28, 2023 and completed offsite on November 30, 2023, at Ppsp Far Northeast Health 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:


561.25 LICENSURE Distressed drugs, devices and cosmetics:State only Deficiency.
561.25 Distressed drugs, devices and cosmetics

Drugs, devices and cosmetics which are outdated, visibly deteriorated, unlabeled or inadequately labeled, recalled, discontinued or obsolete shall be identified by the licensed pharmacist or responsible practitioner and shall be disposed of in compliance with applicable Commonwealth and Federal regulations.

Observations:


Based on observation, review of facility policy, and staff interviews (EMP), it was determined the facility failed to discard outdated supplies.

Findings include:

Observation on November 28, 2023, at 12:30 PM, in OR2 (Operating Room) , revealed eleven vacuum curette 14 mm curved cannula's with an expiration date of June 30, 2022, one vacuum curette 14 mm curved cannula's with an expiration date of May 20, 2023 and three vacuum curette 14 mm curved cannula's with an expiration date of July 30, 2023.

Observation on November 28, 2023, at 12:45 PM in OR2, revealed a four (4) oz bottle of lubricating jelly with an expiration date of November 24, 2022.

Request was made to EMP3 on November 28, 2023, for the facility's policy that addressed removing expired supplies from inventory. None was provided.

Interview conducted on November 28, 2023, at 12:50 PM with EMP1 and EMP3 confirmed the above findings.













 Plan of Correction - To be completed: 03/31/2024

On 11/28/23, outdated supplies (cannulas and jelly) found during the inspection were immediately discarded and facility staff thoroughly reviewed all additional supplies within the procedure rooms for expiration dates.

The Administrator (Center Manager) will train all center staff on proper inventory management including storage by expiration date and removal of all expired items by 1/31/24. In addition, the Director of Patient Services will update the Infection Control Plan to include specific instructions regarding the removal of expired supplies.

The Administrator (Center Manager) will ensure monthly review of inventory and removal of any expired items by assigning medical supply inventory to facility Medical Assistants. The Medical Assistant will document completion of medical supply review and removal of expired items on RQM log which will require review (and sign-off) by a second staff person. Expired items will be removed monthly as part of the monthly RQM tasks.

The Administrator (Center Manager) is responsible for ensuring management and monitoring of supplies including discarding outdated supplies. They will audit medical supplies twice monthly for 3 months (through March 2024) and if no findings will move to monthly oversight starting in April 2024. Documentation of auditing activities will be made on the RQM log and communicated with facility team. The RQM Coordinator will review monitoring activities and perform random checks for expired supplies during quarterly site visits and work with the Facility Administrator (Center Manager) to address any concerns.

Monitoring activities including audit findings will be reported to the facility's Patient Safety Committee (next meeting TBD March 2024) and to the Governing Board as part of the quarterly CRQM report. Final copies of Committee and Board meeting minutes will be available for DOH review.



567.41 LICENSURE MAINTENANCE SERVICE - Principle:State only Deficiency.
567.41 Principle

The ASF shall be equipped, operated and maintained to sustain its
safe and sanitary characteristics and to minimize health hazards in the ASF
for the protection of patients and employes.

Observations:


Based on observation , a review of facility policy and procedures, and interview with staff (EMP), it was determined the facility failed to maintain a clean and sanitary environment.

Findings include:

Observation on November 28, 2023, of OR2, at approximately 10:50 AM, revealed used latex gloves on the operating room floor and an ultrasound machine was unclean.

Further observation on November 28, 2023, revealed a small refrigerator (with freezer) in the facility's dirty/contamination room, with blood-like substances at the bottom of the inside of the refrigerator.

A review on November 28, 2023, of facility policy "Cleaning of Equipment" dated June 19, 2012 revealed, "Contaminated work surfaces shall be decontaminated and disinfected with an appropriate disinfectant at the following times: after completion of procedures, immediately or as soon as feasible when surfaces are overtly contaminated,after any spill of blood or other potentially infectious materials, at the end of the work shift if the surface may have been contaminated since the last cleaning..."

An interview conducted on November 28, 2023, at 10:45 AM with EMP 1 confirmed the above findings.








 Plan of Correction - To be completed: 02/29/2024

By 1/31/24, the Facility Administrator (Center Manager) will provide staff training/education on updated cleaning requirements, including policy review and demonstration, to all facility staff. The facility's Infection Control Plan will be updated to include new cleaning expectations, use of daily log and monitoring activities. In addition, the contracted Cleaning Services Company will be notified of need for improved cleaning.

No later than 1/31/24, the facility will implement updated cleaning procedures for the procedure rooms and the bio-hazard freezer. An updated cleaning log for procedure rooms will be used daily, assigned staff (medical assistants) will complete cleaning tasks as listed (including ensuring no items on floor and all equipment clean), check off tasks completed and sign off on the log. A second staff person (manager, charge person, senior staff) who will sign-off on the cleaning log will monitor cleaning daily. The Administrator will communicate the requirement that the freezer must be kept clean will be communicated to all center staff (via email) and a log will be used to document that the freezer was checked and cleaned as needed. The Administrator will closely monitor cleaning activities weekly for 2 months, then monthly to ensure ongoing compliance to corrective action. The logs, cleaning and freezer, will be monitored weekly (then monthly) by the Facility Administrator, and quarterly by the Risk and Quality Management Coordinator.

Ongoing management and monitoring of facility cleanliness is the responsibility of the Administrator (Center Manager) with support from the Director of Facilities and Director of Patient Services. Monitoring activities including audit findings will be reported to the facility's Patient Safety Committee (next meeting TBD March) and to the Governing Board as part of the quarterly CRQM report. Final copies of Committee and Board meeting minutes will be available for DOH review no later than 2/29/24.



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