QA Investigation Results

Pennsylvania Department of Health
ALLEGHENY REPRODUCTIVE HEALTH CENTER
Health Inspection Results
ALLEGHENY REPRODUCTIVE HEALTH CENTER
Health Inspection Results For:


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Initial Comments:


This report is the result of an Annual Registration survey conducted on November 6, 2023,
with continued document review through November 8, 2023, at the Allegheny Reproductive 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 on November 6, 2023,
with continued document review through November 8, 2023, at the Allegheny Reproductive 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:




555.3 (d)(1) LICENSURE
Requirements

Name - Component - 00
555.3 Requirements for membership and privileges.

(d) Granting of clinical privileges shall follow established policies and procedures in the bylaws or similar rules and regulations the procedures shall provide the following.
(1) Written record of the application, which includes the scope of
privileges sought and granted. The delineation "clinical privileges" shall address the administration of anesthesia.


Observations:



Based on a review of credential files (CF) and staff interview (EMP), it was determined the facility failed to include scope of privileges sought and granted in the clinical privileges application for eight of eight credential files reviewed (CF1, CF2, CF3, CF4, CF5, CF6, CF7 and CF8).



Findings include:



On November 6, 2023, review of facility's "Medical Staff Bylaws", last reviewed 10/16/2023, revealed: " ... Granting of privileges shall follow established policies and procedures in the bylaws or similar rules and regulations. The procedures shall provide the following: (1) A written record of the application which includes the scope of privileges sought and granted. ... ".



On November 6, 2023, review of CF1, CF2, CF3, CF4, CF5, CF6, CF7, and CF8
revealed that within the last two years, each of these individuals received a letter confirming that privileges were granted, but their corresponding applications did not include privileges sought and granted.



On November 6, 2023, at approximately 10:45 AM, EMP1 confirmed the above.










Plan of Correction:

For licensed providers, granting of privileges shall follow established policies and procedures in the medical staff bylaws. We have developed a written record of the application which includes the scope of privileges sought and granted for licensed providers seeking privileges at ARHC.


569.34 LICENSURE
Electrical Safety

Name - Component - 00
569.34 Electrical Safety

Appliances, instruments and installations shall be tested before
use to determine compliance with grounding, current leakage and other
device safety requirements to ensure protection of patients and employees. A
program of routine maintenance shall be effectively enforced to ensure that
electrical receptacles and plugs, wires and connectors are safe. If an
appliance requiring three wire circuitry for grounding is attached to
as two wire outlet, the adaptor plug pigtail shall be attached to a
ground.


Observations:



Based on a review of facility documentation and staff interview (EMP), it was determined the facility failed to ensure routine maintenance of electrical receptacles and plugs, wires and connectors.



Findings include:


When asked for a protocol or policy to address routine maintenance of electrical receptacles, EMP1 responded the facility did not have such a document.


When asked for evidence that electrical receptacles were routinely checked for safety, EMP1 was unable to provide documentation of routine maintenance.


During interview with EMP1 on November 6, 2023, at approximately 1:00 PM, EMP1 confirmed the above information.








Plan of Correction:

We will ensure documentation of our routine monthly maintenance of electrical receptacles and plugs, wires and connectors.