QA Investigation Results

Pennsylvania Department of Health
PLANNED PARENTHOOD KEYSTONE - YORK
Health Inspection Results
PLANNED PARENTHOOD KEYSTONE - YORK
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced Special Monitoring survey conducted on May 14, 2024, at Planned Parenthood Keystone - York. It was determined the facility was not 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:




29.33(7) STANDARD
Requirements for Abortion

Name - Component - 00
Rho (D) - - immune globin (human) shall be administered to each Rh-negative patient at the time of any abortion, unless contraindicated. Evidence of compliance with this paragraph shall appear in the medical record of the patient. If for any reason the patient refuses the administration of Rh immune globulin when recommended, this refusal shall be noted in the clinical record of the patient.

Observations:

Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow their policy to ensure proper documentation of administration or refusal of Rho (D) Immunoglobulin injection in one out of five Rh-negative patients reviewd (MR10).
Findings include:
Review on May 14, 2024, of facility policy "PRE-ABORTION LAB REQUIREMENTS" with a last review date of April 1, 2024, revealed "RH Typing ... 3) If Rh-negative, a) Rho (D) Immunoglobulin will be prescribed and administered as indicated, in accordance with the Medical Standards and Guidelines. APC or Physician orders Rho (D) Immunoglobulin. APC or Physician can administer Rho (D) Immunoglobulin directly or delegate duty of administration to trained licensed staff. b) Staff members administering injections are responsible for documentation in EHR. c) If the patient refuses Rho (D) Immunoglobulin, they must sign the appropriate release (Release When Test Not Obtained with Rh language checked off)."
Review of MR10 on May 14, 2024, revealed the patient was determined to be Rh-negative (a blood group that lacks the Rh antigen in the red blood cell). There was documentation noted that the patient received or refused the Rho (D) Immunoglobulin (a medication used to prevent antibodies from forming and to avoid complications with future pregnancies) injection.
Interview with EMP1 on May 14, 2024, at approximately 11:00 AM confirmed that there was no documentation in MR10 that the patient received or refused the Rho (D) Immunoglobulin injection.





Plan of Correction:

Center Management will conduct a retraining on compliant documentation for RH negative patients in the electronic health record system for clinic staff during a staff meeting.

This training will include:
1. How to document when a RH negative patient receives or declines Rho(D)
2. A review the checkout-process and how to double check RH negative patients' charting for compliance as a part of oversight.
3. A discussion that the RQM Manager will be conducting audits and providing feedback if non-compliances are noted.

This training will be completed by 6.13.2024 and documented minutes to the training will be retained.

The RQM Manager will conduct audits on a monthly basis until 100% compliance is achieved starting on 6.1.2024. All non-compliances will be reported to Center Management for remediation with involved staff members and to the Director of RQM.